Endoscopic Diagnosis and Treatment of Biliary Tract Disease

Symposium on Biliary Tract Disease

Endoscopic Diagnosis and Treatment of Biliary Tract Disease Howard A. Shapiro, M.D. *

ENDOSCOPIC RETROGRADE CHOLAN-GIOGRAPHY Endoscopic retrograde cholangiopancreatography (ERCP) was first described in 1968 by McCune et al.," but its widespread use awaited the availability of new duodenoscopes in 1970. Within two years there were worldwide reports on the use of these instruments to accomplish radiographic visualization of the pancreatic duct and biliary tree. The initial concern was with the technical feasibility of ERCP. As early as 1972 most major groups were reporting success rates of 70 to 85 per cent in visualizing the desired duct system. With experience, the success rate has continued to improve. The next major concern was with the safety of ERCP. In 1975 and 1976 two excellent surveys reported an acceptably low complication rate with an experienced operator." 17 The next major concern, its clinical relevance, is still being evaluated.

Technique Endoscopic equipment has changed very little since the introduction of the long-side viewing duodenoscope. With succeeding generations of instruments, the major advances have been an increase in the arc of tip deflection, insulation of the duodenoscope tip to increase the safety of electrosurgery, and a greater retroflexion in the plane of the distal optical window to assist in selective cannulation of the common bile duct. Standard forward viewing panendoscopes are unsuitable except following choledochoduodenostomy or Billroth II gastrojejunostomy. The choice of drugs for sedation has never been critically important; we use diazepam or meperidine, or both, given intravenously to the point of cooperative somnolence. After the endoscope has entered the duodenum, ileus is imperative. Anticholinergic agents have been standard in producing duodenal atony, but in the past five years, our preference has been to administer small increments of glucagon (0.5 mg) intravenously to attain this end and thereby avoid anticholinergic side effects. *Clinical Professor of Medicine, Department of Medicine and the Liver Center, University of California, San Francisco, California Supported in part by the Walter C. Pew Fund for Gastrointestinal Research.

Surgical Clinics of North America-Vol. 61, No.4, August 1981

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After the patient has been adequately sedated, the side viewing duodenoscope is passed into the esophagus with the patient lying in the left lateral position. The distal esophagus, stomach, and proximal duodenum are inspected directly. The papilla of Vater is generally located on the posteromedial wall of the middle third of the descending duodenum, but variability in its location is not unusual. The pancreatic duct is entered more readily and, if cholangiography is desired, the cannula should be placed in the roof of the papilla bowed so that it is angled up toward the liver. Experience favors success, and in our last 300 studies we were able to obtain cholangiograms, when desired, in/90 per cent of patients. Failures were usually associated with major disease or previous surgery. The cholangiopancreatography of ERCP is a radiologic procedure that requires excellent equipment and trained personnel. Inferior radiographs may render the entire procedure useless. Standard water-soluble iodinated contrast material is used. It should be diluted 50 per cent if a dilated bile duct is visualized. If the contrast is too concentrated small filling defects may be missed. Enough contrast agent is injected to provide excellent radiographs as judged by careful fluoroscopic monitoring of the injection process; the volume is unimportant.

Contraindications Endoscopic retrograde cholangiopancreatography cannot be done on an uncooperative patient, as patient and endoscopist can be hanned and the duodenoscope can be damaged. Contraindications are relative and depend on a clinical decision as to whether the information gained is worth the risks involved. Patients with cardiac or pulmonary disease are at risk from the medication given and should be monitored closely. A recent history of acute pancreatitis is a relative contraindication unless a surgically remedial situation is anticipated. Hepatitis A, B, or non-A non-B is not a contraindication. Recent epidemiologic studies have failed to substantiate a single case of endoscopically transmitted hepatitis. Allergy to iodinated dye is an indication for ERCP rather than a contraindication. In a recent survey mild urticarial reactions occurred in only three of 8861 patients. Anaphalaxis has never been reported."

Complications The complication rate falls dramatically with increased operator experience.": 17 This is a compelling argument for permitting only experienced endoscopists to perform ERCP. In such experienced hands a complication rate of 1 to 3 per cent may occur, with a mortality rate of 0.1 per cent. The major complications are pancreatitis and sepsis. The serum amylase concentration becomes significantly elevated in 25 to 75 per cent of patients undergoing pancreatography." The elevation is generally asymptomatic. The clinical picture of acute pancreatitis with severe abdominal pain occurs in 1 per cent, generally is mild, and is nonfatal. Pancreatic sepsis is a potentially lethal complication with an incidence of 0.3 per cent. In the 25 such cases reported in Bilbao's survey, eight had partial duct obstruction and 17 pseudocysts. Early decompressive surgery is indicated. There is an 0.8 per cent incidence of biliary sepsis, and it almost always occurs in the presence of a partially

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obstructed bile duct. If this situation is anticipated, prophylactic antibiotic therapy and the planning of early decompressive surgery are advisable. Cardiopulmonary complications, injuries by instruments, and drug reactions should become increasingly rare as experience is gained.

Diagnostic Value In differentiating surgical from nonsurgical biliary tract disease, the demonstration of a normal cholangiogram significantly reduces the need for exploratory laparotomy. Should an obstructing lesion be found, the cholangiogram directs the surgeon's hand and reduces operating time, morbidity, and mortality. Radiographs of the biliary tree are familiar to radiologists and clinicians and their interpretation usually poses no problem. The Normal Cholangiogram. The normal endoscopic cholangiogram has a mean maximum duct width of 4.6 mm and an upper normal limit of 9 mm (Fig. 1). There is a slight increase in the size of the common hepatic duct with increased age and in patients with significant liver disease." The measurements of duct size are consistently 3 mm greater on ERCP than on intravenous cholangiogram. In the absence of prior cholecystectomy, nonfilling of

Figure 1. In this normal cholangiogram, the common duct is of uniform caliber, the intrahepatic ducts are well seen, and the gallbladder is incompletely filled.

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the cystic duct suggests obstruction. The common bile duct does not dilate following cholecystectomy; common duct dilatation suggests obstruction. In interpreting large ducts, comparison with a prior operative cholangiogram is helpful and delayed drainage films are important. After cholecystectomy a normal bile duct should drain completely in 45 minutes. Jaundice. Clinical judgment is usually correct in the diagnosis of jaundice, but in many situations it is difficult to differentiate between medical and surgical causes. If surgical jaundice is suspected, noninvasive radiologic tests are helpful. Abdominal sonography'" and C'I'
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Figure 2, Sclerosing cholangitis. There is irregular beading and dilatation throughout the biliary tree. The pancreatic duct fills through a common channel and is normal.

Primary biliary cirrhosis usually presents with hepatomegaly, and the cholangiogram shows stretched, widely spaced, narrow intraheptic ducts. Cholangiocarcinoma of the intrahepatic ducts may involve only one of the major ducts but more commonly occurs at the bifurcation of the common duct (Fig. 4). The stenosis is irregular and may be associated with dilatation of the proximal bile duct. Hepatoma will either displace, invade, or encase the intrahepatic bile ducts. There may be dilatation proximal to a partially obstructing lesion. Metastatic lesions produce cholangiographic changes only if they are of sufficient size or if they directly impinge on the intrahepatic bile ducts. Infestation with Clonorchis sinensis produces saccular dilatation within the entire intrahepatic biliary tree (Fig. 5). Diseases of the Extrahepatic Biliary Tree. Choledocholithiasis, with or without an intact gallbladder, is the most common cause of extrahepatic obstruction of the bile duct (Fig. 6).22 The bile duct, though usually dilated, may be of normal size even in the presence ofjaundice. This is a major cause of false-negative abdominal sonograms and CT scans. Stones vary in number, size, and contour; they may be faceted or smooth. If smooth, they may be difficult to distinguish from inadvertently injected air bubbles unless erect films are taken. The bubbles float and the stones sink. Concomitant stricture or tumor must be excluded since either can coexist with gallstones and may be the primary cause of obstructive jaundice.

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Figure 3. Postnecrotic cirrhosis. There is intrahepatic duct crowding and tortuosity due to reduced liver volume. The common bile duct and pancreatic duct are normal. The gallbladder is absent.

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Figure 4. Cholangiocarcinoma. This tumor, at the bifurcation of the common bile duct, is associated with proximal intrahepatic dilatation.

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Figure 5. Clonorchis sinensis infestation. There is irregular saccular dilatation of the intrahepatic biliary tree with a normal common bile duct. The filling defects that can be seen within the sacculation probably represent parasites.

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Figure 6. This patient had stones in the common duct. After this cholangiogram was taken, an endoscopic sphincterotomy was done and all stones were removed.

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Strictures may be benign or malignant and may cause total or incomplete obstruction of the common bile duct. The degree of duct dilatation bears no steady relationship with either the degree or duration of obstruction. This can also contribute to false-negative interpretation of abdominal sonograms or CT scans. Strictures of the mid-duct must be presumed to be malignant if there has been no prior biliary tract surgery or trauma. Those due to cholangiocarcinoma generally have an abrupt cutoff or a "rat-tailed" appearance. Those due to metastatic disease, lymphoma, or locally invasive carcinoma of the pancreas or gallbladder are generally more smoothly tapered. If there has been prior biliary tract surgery, the cause of a mid-duct stricture is probably secondary to that surgery (Fig. 7). The distinction of benign from malignant stricture on radiographic grounds alone may be difficult to make. The criteria for differentiating benign from malignant strictures in the distal common duct are imprecise. One cannot rely on the length, symmetry, contour, or margin irregularity. An attempt must be made to obtain a simultaneous pancreatogram, since this often assists in this differential diagnosis. Concomitant changes of chronic pancreatitis suggest a benign stricture (Fig. 8). If the pancreatogram suggests carcinoma, the stricture is probably due to

Figure 7. This patient had a postsurgical mid-duct stricture. There are abrupt stricture margins and there is a small stone proximal to the stricture. Despite the patient's intense jaundice at the time of this study, the caliber of the proximal and intrahepatic bile ducts is normal.

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Figure 8. Common duct stricture secondary to chronic pancreatitis. A markedly dilated pancreatic duct with ectasia of the secondary branches is partially obscured by the duodenoscope.

encasement of the tumor or direct extension into the bile duct (Fig. 9). In carcinoma of the papilla of Vater, the diagnosis will be apparent at endoscopy and confirmed by brush cytology and target biopsy. Cannulation is usually possible and helps to define the extent of the tumor. Stenosis of the papilla of Vater is suggested clinically by painful cholestatic episodes in patients with prior cholecystectomy (Fig. 10). It is confirmed radiographically by demonstration of dilatation of the common duct accompanied by slow (longer than 45 minutes) drainage of contrast from the biliary tree. The- pancreatic duct also may be dilated. Manometry of the sphincter of Oddi is a new technique that promises to define this entity more closely."

Following Common Duct Diversion. Anastomosis of the common bile duct with the posterior duodenal bulb is an accepted means of biliary decompression. Subsequent jaundice and/or cholangitis is a serious late complication that is most often due to stricture at the anastomotic site. This possibility can best be evaluated by endoscopic cholangiography. If a stricture is found, it can be dilated at the time of the diagnostic endoscopy. In side-to-

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Figure 9. In this patient with carcinoma of the pancreas, the intrapancreatic portion of the common bile duct (CBD) is completely obstructed. The pancreatic duct (PD) is partially obstructed with moderate upstream dilatation. At surgery the lesion was 2.5 cm in diameter.

side choledochoduodenostomy the defunctionalized length of bile duct between the anastomosis and the papilla of Vater may act as a reservoir (sump) for undigested food and a nidus for bacterial infection. Endoscopic retrograde cholangiopancreatography can define this condition (Fig. 11), and endoscopic sphincterotomy can be curative by allowing adequate drainage of the distal bile duct." If the biliary decompression chosen by the surgeon is a choledochojejunostomy, the Roux-en-Y loop can be brought subcutaneous to the anterior abdominal wall. In the event of subsequent stenosis at the anastomotic site, endoscopic cholangiography and direct dilatation of the stricture is possible by means of the subcutaneous Roux-en-Y loop.

ENDOSCOPIC SPHINCTEROTOMY Approximately 600,000 cholecystectomies are performed each year in the United States." Even though it is unusual for a surgeon to overlook or to leave stones within the common bile duct during biliary tract operations, about 30,000 patients per year will have retained, residual, or recurrent com-

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Figure 10. This patient had papillary stenosis. There is marked dilatation of both the biliary tree and the pancreatic duct. Endoscopic sphincterotomy was curative.

Figure 11. "Succotash" cholangitis. The cannulation is through the widely patent stoma of the choledochoduodenostomy. Vegetable debris can be seen in the distal common duct.

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mon duct stones.l''i " Endoscopic retrograde cholangiopancreatography is now one of the standard means of investigating such patients. Transendoscopic incision of the papilla of Vater and extraction of common duct stones became possible with further refinements of the side-viewing duodenoscope and the development of a diathermy sphincterotome. In 1974 the first reports of this operation originated in japan!" and Cermany," and in the ensuing three years there was worldwide interest in this technique as an alternative to operative choledochotomy and stone extraction.?: 16. 19 In the five years since its introduction to the United States it has become an accepted means of treatment of choledocholithiasis in patients who have undergone prior cholecystectomy.'

Indications Endoscopic sphincterotomy is the procedure of choice in removing residual or recurrent bile duct stones. In the case of retained common duct stones, when a suitable T -tube is in place, percutaneous extraction of the stone is preferred" and endoscopic sphincterotomy should be performed only if this safer technique has failed. Endoscopic sphincterotomy is appropriate for removal of common duct stones in the high risk patient with an intact gallbladder. Gallstone pancreatitis is well treated by endoscopic sphincterotomy and results in prompt resolution of pancreatitis. It is preferable to exploration of the common duct in those with prior cholescystectomy and offers excellent palliation for those with an intact gallbladder who are at high surgical risk. Definitive cholecystectomy can follow. These guidelines can be applied to patients with acute cholangitis. Stenosis of the papilla of Vater is difficult to define, both clinically and anatomically. A working diagnosis includes the features of recurrent epigastric or right upper quadrant abdominal pain similar to that of biliary origin, biochemical evidence of intermittent or constant cholestasis (elevated levels of serum bilirubin or alkaline phosphatase of hepatic origin) or pancreatitis (elevated serum amylase), dilatation of the common bile duct and occasionally the pancreatic duct on ERCP, and delayed drainage of contrast material from the common bile duct (longer than 45 minutes) following ERCP. With use of sphincter of Oddi manometry at the time of ERCP, elevated sphincter pressure is confirmatory. 7 If the gallbladder is intact, the diagnosis cannot be made without manometry, since post-ERCP delayed-drainage films cannot be interpreted with accuracy. In patients with tumors of the papilla of Vater, palliation of jaundice and pruritus will occur following endoscopic sphincterotomy.': 19 This should be done only in those at significant surgical risk since definitive surgery (Whipple procedure) has a high cure rate in otherwise healthy patients. It can be used as a temporary measure in converting a poor risk patient to one better able to withstand surgery. In selected patients with malignant obstruction of the common bile duct, palliation of jaundice has been achieved by duodenoscopic placement of biliary stents." The" sump" syndrome is an infrequent complication of side-to-side choledochoduodenostomy. Foreign material may accumulate in the bypassed segment of the distal common duct and act as a nidus for recurrent cholangitis.!" Endoscopic sphincterotomy permits clearance of debris or stones from the distal common duct.

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Contraindications Significant coagulation defects are detected by always obtaining a screening prothrombin time, partial thromboplastin time, and platelet count. A long stricture of the distal common duct would increase the risk of duodenal perforation or pancreatic damage. L 5. 16. 19 In patients with very large common duct stones (larger than 2.5 em in diameter), operative intervention is preferable to endoscopic sphincterotomy. However, in poor risk patients with large stones, several nonoperative options exist if sphincterotomy is performed. Surprisingly, some stones pass spontaneously. Sometimes they can be crushed with a Dormia basket and the fragments extracted with a balloon tip catheter. A long-retention catheter can be placed in the proximal common duct following sphincterotomy with the other end routed out through the mouth or nose and left in place for several weeks. This allows perfusion of the common duct with a gallstone-dissolving agent such as sodium cholate or mono-octanoiri," thereby facilitating stone passage through the sphincterotomy opening. Perivaterian duodenal diverticula, impacted gallstones, and prior subtotal gastrectomy with Billroth II anastomosis are not contraindications for endoscopic sphincterotomy. There may be technical difficulty in identifying the papilla or in properly seating the sphincterotome; either can prevent success but should not preclude an attempt.

Technique Prior to performance of endoscopic sphincterotomy, informed consent must be obtained, with a careful explanation to the patient and family of alternative forms of treatment, details of the procedure, relative risks, and relative benefits." Expert surgical back-up is essential should a complication develop. Antibiotics should be used prophylactically in patients with common duct obstruction but can be discontinued following successful relief of obstruction. Initially a diagnostic ERCP is performed. This is crucial to the decision as to whether or not sphincterotomy is technically feasible or advisable. Findings that influence advisability include the size and number of intraductal calculi, the presence of a biliary stricture, the length of the intraduodenal segment of the bile duct, the presence and location of perivaterian diverticula, and the presence or absence of associated diseases whose management might require surgery. Following the diagnostic ERCP the sphincterotome is passed deeply and selectively into the common bile duct. The Erlangen model is most frequently used in the United States and consists of an electrosurgical wire enclosed in a Teflon catheter, an adjusting handle, and a side port for injecting contrast material. The distal 2 to 4 em of wire is exposed and functions as the electrosurgical cutting edge. The adjusting handle is used to bow the cutting wire and it is attached to a diathermy unit. After radiographic confirmation of the selective placement of the sphincterotome within the common duct (Fig. 12), it is withdrawn so that approximately 1.5 em of the wire is visible in the duodenum outside the papillary orifice. The length of the intramural segment of the common duct is usually visible as a bulge superior to the papillary orifice. The wire is oriented in the 12,0' clock position in relation to the papilla by flexion of the cutting wire and manipulation of the directional

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Figure 12. In this cholangiogram the sphincterotome is properly placed within the bile duct prior to endoscopic sphincterotomy.

tip of the duodenoscope. A blended diathermy current is then applied so that a measured cut of sufficient length can be made through the sphincter muscles to allow the passage of the previously identified stone. The orifice can be measured with a balloon tip catheter and is generally 1 to 1.8 ern in diameter. It makes good sense to remove the calculus at the time of sphincterotomy in order to preclude the possibility of reimpaction of the calculus with subsequent cholangitis. This also obviates the need for another endoscopic evaluation. A balloon tip catheter is the preferred stone extractor (Fig. 13). After deep passage into the proximal common duct, it is inflated. Using a radiographic monitor the balloon is pulled down the bile duct, sweeping the stone before it. If the bile duct is quite dilated or the stone large, this technique may fail. In that case a wire Dormia basket can be passed under fluoroscopic guidance and an attempt made to engage the stone within the basket so that it can be extracted or fragmented (Fig. 14). If this fails, a period 'of one week of observation is indicated, then a diagnostic ERCP is repeated. Sixty per cent of stones will have passed spontaneously. Those remaining can be extracted as described. By following this plan, few stones will remain and those are usually larger than 2 em. In this case a long indwelling catheter can be left in the proximal bile duct and the duct infused with a gallstone-dissolving agent prior to consideration of surgery.

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Figure 13. A, Immediately after endoscopic sphincterotomy, an inflated balloon-tip catheter was placed deep within the bile duct and above several common duct stones.

Illustration continued on the following page.

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Figure 13 (Continued). B, The balloon-tip catheter has been partially withdrawn, expressing the most distal stones into the duodenum.

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Figure 14. The Dormia basket is seen extended at the moment before this common duct stone was entrapped and extracted.

Following successful stone extraction, the patient is observed in hospital, placed on a progressive diet, and generally discharged in 48 hours. The severity of complications influences the length of the hospital stay.

Results At the University of California Medical Center, San Francisco, we attempted endoscopic sphincterotomy in 81 patients, ranging in age from 42 to 98 years (mean, 72.6 years). The indications for sphincterotomy were common bile duct stone(s) in 68 patients, papillary stenosis in 11, carcinoma of the ampulla of Vater in 1, and "sump" syndrome in 1. Of the 68 with common duct stones, 63 had previously undergone cholecystectomy, five had gallbladders in situ and were poor surgical risks, and 20 had retained stones shortly after cholecystectomy. Of those 20, eight with T-tubes in place had unsuccessful attempts at stone extraction through the T -tube tract. Most pa-

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tients had severe coincident medical problems that included morbid obesity, cardiorespiratory insufficiency, and advanced liver disease. Sixty-four patients were referred by surgical colleagues. Sphincterotomy was successful in 73 patients (90.1 per cent). In seven patients there was failure because of inability to pass the sphincterotome deeply within the common bile duct. The majority of these failures occurred early in our series, and as experience was gained our success rate improved. In one patient a very large stone (3 em) would not pass through a seemingly adequate sphincterotomy. In 16 patients an adequate sphincterotomy was accomplished only after two or more sessions, either because of mechanical failure (such as broken sphincterotome or faulty duodenoscope) or because the initial sphincterotomy was deemed inadequate on follow-up ERCP. In the 68 patients with stones in the common bile duct, endoscopic sphincterotomy and stone extraction was successful in 63 (92.6 per cent). In the one patient whose 3 em stone would not pass through a seemingly adequate sphincterotomy, surgery was refused. In the two years that she has been observed subsequent to sphincterotomy, she has had only minor problems with intermittent fever that have been responsive to outpatient antibiotic therapy. Hospitalization has not been required. The patients with papillary stenosis all met the criteria of recurrent biliary pain, biochemical findings associated with cholestasis, dilated common duct after cholecystectomy, and impaired biliary drainage following diagnostic ERCP. One patient had manometric studies performed at another institution that supported the diagnosis of papillary stenosis. Of the 11 sphincterotomies attempted, eight (72.7 per cent) were successful, with complete amelioration of symptoms in six (54.5 per cent). One patient with prior cholecystectomy and choledochoduodenostomy for stones of the common duct associated with marked common duct dilatation underwent endoscopic sphincterotomy with mechanical cleansing of the distal duct. He had had recurrent bouts of cholangitis, presumed to be secondary to entrapment of debris in the duct distal to the anastomosis (U sum p" syndrome). He has had no symptoms in the eight months since sphincterotomy. An 87 year old man with carcinoma of the papilla of Vater on biopsy underwent endoscopic sphincterotomy for palliation of symptoms of jaundice and pruritus. He is now asymptomatic 10 months after sphincterotomy. All patients are being followed clinically and have had follow-up ERCP when indicated. An approximate 30 per cent contraction of the sphincterotomy orifice as measured by balloon tip catheter occurs within six to 12 months, followed by no further shrinkage. Patency of the sphincterotomy can be demonstrated by plain films of the abdomen that show air within the biliary tree or by an upper gastrointestinal tract series showing barium reflux into the bile duct.

Complications Seven patients (8.6 per cent) developed complications, of which duodenal perforation was the most serious. Both patients with duodenal perforation required surgery, one within 24 hours and another after retroperitoneal fluids were found to collect following four days of conservative management. Both patients are now well. Two patients had significant bleeding after

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sphincterotomy, and both recovered uneventfully after the transfusion of two units of blood. Of the two patients who developed pancreatitis after sphincterotomy, one had mild disease that resolved after five days of conservative therapy. The other developed a small pancreatic abscess and recovered after four weeks of intravenous hyperalimentation and antibiotic therapy. One patient developed aspiration pneumonia, which resolved with antibiotic therapy. Although stone impaction and cholangitis are possible complications of endoscopic sphincterotomy, they did not occur in any of our patients. There have been no fatalities.

Discussion Endoscopic sphincterotomy has proved to be an effective, safe, and costefficient method for removing stones of the common duct and relieving benign and malignant obstructions of the papilla of Vater.': 5, 16, 19 In this series of 81 patients, the success rate was high (90.1 per cent), the morbidity rate low (8.6 per cent), and the mortality zero. These rates are similar to those reported by others. The rapid acceptance of this procedure is reflected by the increasing demand for it and the proliferation of published series of cases. Some words of caution seem appropriate. The technique is difficult and should be attempted only by an endoscopist who is thoroughly familiar with the anatomy of the sphincter area, understands the capabilities of the endoscope and electrosurgical unit, and has expertise in selective cannulation of the common bile duct. The latter ability is achieved only after one has performed hundreds of diagnostic ERCPs. The precise indications for endoscopic sphincterotomy are still evolving and will be defined with certainty only after its risks and benefits have been compared with those of alternative methods of treatment. In the young, healthy postcholecystectomy patient with residual or recurrent stones, we still do not know the long-term effects of endoscopic sphincterotomy. To date, they do not appear to be harmful. Restenosis has not been a significant problem. In the patient with retained stones and an adequately sized T-tube in place, it is preferable to attempt stone extraction through the T-tube tract," reserving endoscopic sphincterotomy for failed extractions. In the patient with an intact gallbladder, cholecystectomy and choledochotomy are preferable to sphincterotomy. Endoscopic sphincterotomy should be performed only if the patient is elderly or at increased surgical risk. In the long term, such patients who do not undergo cholecystectomy may develop cholecystitis. These caveats notwithstanding, the documented simplicity, success, and low complication rate lead one to a strong preference for endoscopic sphincterotomy in all patients with residual or recurrent stones after cholecystectomy and in those at high surgical risk with their gallbladders in situ. The occasional failure of this technique does not preclude further surgery. The diagnosis of papillary stenosis remains elusive and depends on clinical judgment. Current attempts at closer definition of this entity by the use of manometric measurements of pressure at the sphincter of Oddi? may allow a more appropriate selection of patients who will benefit from endoscopic sphincterotomy.

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ACKNOWLEDGMENTS

I am indebted to the medical and nursing staff of the Gastrointestinal Diagnostic Center, my radiologist colleagues (Drs. Alexander Margulis, Henry Goldberg, and Albert Moss), and the many physicians who have referred their patients to my care. This work would not have been possible without the encouragement and support of my surgical colleagues (Drs. Lawrence Way, Thomas Hunt, and Theodore Schrock).

REFERENCES 1. Allen, B., Shapiro, H. A., and Way, L. W.: Management of recurrent and residual common duct stones. Am. J. Surg., in press. 2. Bilbao, M. K., Dotter, C. T., Lee, T. G., et al.: Complications of endoscopic retrograde cholangiopancreatography (ERCP): A study of 10,000 cases. Gastroenterology, 70:314, 1976. 3. Burhenne, H. J.: Percutaneous extraction of retained biliary stones: 661 patients. A. J. R., 134 :888, 1980. 4. Classen, M., and Demling, L.: Endoscopic Spincterotomie der Papilla Vateri. Dtsch. Med. Wochenschr., 99:496,1974. 5. Cotton, P. B.: Non-operative removal of bile duct stones by duodenoscopic sphincterotomy. Br. J. Surg., 67:1, 1980. 6. Ferrucci, J., Wittenberg, J., Sarno, R., et al.: Fine needle transhepatic cholangiography-a new approach to obstructive jaundice. A. J. R., 127:403, 1976. 7. Geenen, J. E., Walter, J. H., Dodds, W. J., et al.: Intraluminal pressure recording from the human sphincter of Oddi. Gastroenterology, 78:317, 1980. 8. Greenberg, H. M., Goldberg, H. I., Shapiro, H. A., et al.: The importance of radiographic monitoring in endoscopic sphincterotomy. Radiology, in press. 9. Havrilla, T. R., Haaga, J. R., Alfidi, R. J., et al.: Computed tomography and obstructive biliary disease. A. J. R., 128:765, 1977. 10. Kawai, K., Akasaka, Y., Murakami, M., et al.: Endoscopic sphincterotomy of the ampulla of Vater. Gastrointest. Endosc., 20:148, 1974. 11. Lasser, R. B., Silvis, S. L., and Vennes, J. A.: The normal cholangiogram. Am. J. Dig. Dis., 23:586, 1978. 12. Laurence, B. H., and Cotton, P. B.: Decompression of malignant biliary obstruction by duodenoscopic intubation of bile duct. Br. Med. J., 280:522, 1980. 13. Longmire, W. B.: The diverse causes of biliary obstruction and their remedies. Curro Prob. Surg., 14:7, 1977. 14. Malini, S., and Sobel, J.: Ultrasonography in obstructive jaundice. Radiology, 123:429, 1977. 15. McCune, W. S., Shorb, P. E., and Moscovitz, H.: Endoscopic cannulation of the ampulla of Vater: A preliminary report. Ann. Surg., 167:752, 1968. 16. Nakajima, M., Kizu, M., Akasaka, Y., et al.: Five years' experience of endoscopic sphincterotomy in Japan: A collective study from 25 centers. Endoscopy, 11: 138, 1979. 17. Nebel, O. T., Silvis, S. E., Rogers, G., et al.: Complications associated with endoscopic retrograde cholangio-pancreatography. Results of the 1974 A.S.G.E. survey. Gastrointest. Endosc., 22 :34, 1975. 18. Rohrmann, C. A., Ansel, H. J., Ayoola, E. A., et al.: The endoscopic retrograde intrahepatic cholangiogram: Radiographic findings in intrahepatic disease. Am. J. Roentgenol. Rad. Ther. Nucl. Med., 128:45, 1977. 19. Safrany, L.: Duodenoscopic sphincterotomy and gallstone removal. Gastroenterology, 72:338, 1977. 20. Shapiro, H. A., and Carlson, G.: "Succotash" cholangitis-Diagnosis by retrograde cholangiography. Gastroenterology, 86:824, 1974. 21. Skude, G., Wehlin, L., Maruyama, T., et al.: Hyperamylasemia after duodenoscopy and retrograde cholangiopancreatography. Gut, 17:127, 1976. 22. Thistle, J. L., Carlson, G. I., Hofmann, A. I., et al.: Mono-octanoin, a dissolution agent for retained cholesterol bile duct stones: Physical properties and clinical application. Gastroenterology, 78:1016, 1980. 23. Vennes, J. A., Jacobson, J. R., and Silvis, S. E.: Endoscopic cholangiography for biliary system diagnosis. Ann. Int. Med., 80:61, 1974. 24. White, T. T.: Techniques in treatment of retained gallstones (Editorial comment). West. J. Med., 130 :435, 1979. University of California, San Francisco C-230 San Francisco, California 94143