In a prospective study, the complications observed in 242 consecutive patients after endoscopic sphincterotomy for common bile duct stones were recorded over a period of up to three months. Patients with previous gastric surgery, papillotomy, or additional pancreato-biliary disease other than gallbladder stones were excluded. The overall complication rate was 14%, 74% of these complications being moderate or severe. The complication rate due to cholangitis was higher in (1) the group with retained stones following complete papillotomy and without biliary drainage, and (2) the group with failed precut papillotomy and drainage after cholangiography, both compared to patients with successful drainage (75% vs. 2.6%: p < 0.001 and 40% vs. 2.6%: p = 0.001 respectively). Both pancreatitis and retroperitoneal air leakage occurred in 1.7% of cases. They were more frequently observed in patients with a smaller diameter (< 10 mm) in the distal common bile duct (5.6% vs. 0%: p = 0.007 for pancreatitis, and 2.8% vs. 1.2%; n.s. for perforation) and especially following precut papillotomy (13.0% for pancreatitis and 8.7% for perforation), which had to be performed more often in these patients. Bleeding following sphincterotomy was relatively frequent when the papilla was located at the lower rim of or inside a diverticulum, compared to patients without a diverticulum (16.2% vs. 2.7%: p = 0.004 and 26.7% vs. 2.7%: p < 0.001 respectively). When the papilla was located inside diverticula, both the rate of perforation and bleeding increased following precut papillotomy, compared with standard papillotomy only (33% vs. 0%, n.s., and 33% vs. 22%, n.s.).(ABSTRACT TRUNCATED AT 250 WORDS)

In patients with Billroth II anastomoses, endoprosthesis-guided sphincterotomy is a new and relatively easy procedure, which is especially attractive once selective bile duct cannulation has been achieved. This technique allows the performance of sphincterotomy as a well-controlled procedure, and may, therefore, be safer than nonguided techniques. In contrast to previously reported guided techniques using nasobiliary cannulas, the endoprosthesis technique does not necessitate withdrawing and reinserting the endoscope.

The problems encountered in draining the bile ducts endoscopically in 148 patients with malignant obstruction of the mid or distal common bile duct and/or the papilla were assessed. Endoscopically visible extrinsic invasion of the papilla by a malignancy in the pancreatic head, with or without duodenal stenosis, appeared to be the major reason for the failure to insert a stent. The larger a tumor in the pancreatic head the greater the chance of invasion of the papillary region. This appeared to be evident for tumors restricted to the non-uncinate region of the pancreatic head. We would recommend primary percutaneous biliary drainage or surgery when the size of a proven malignancy restricted to the non-uncinate region of the pancreatic head is 5 cm or more, or when diagnostic duodenoscopy reveals extrinsic invasion of the papilla of Vater, or severe duodenal involvement with stenosis.

In patients suspected of having functional disorders of the papilla it is often difficult to establish the indications whether or not to perform endoscopic papillotomy (EP). We report on thirty-two consecutive patients referred for endoscopic retrograde cholangiopancreatography who all had longstanding biliary tract pain and episodes of liver enzyme elevation indicating cholestasis. Further features were: 1) a dilated common bile duct (CBD) after cholecystectomy (n = 11) or 2) a dilated CBD without or with larger (greater than cystic duct diameter) gallbladder stones (n = 6) or 3) multiple small gallbladder stones, with a normal or dilated CBD, in patients with signs of acute gallstone pancreatitis or in whom elective cholecystectomy was not indicated (n = 15). No CBD stones, organic obstruction or other disorders were found in these patients. Without further diagnostic procedures, EP was routinely performed. The laboratory (up to 3 months) and clinical findings (2 to 4 years follow up) showed improvement in all patients undergoing EP. We conclude that immediate EP appears justified in these selected patients.