Sphincteroplasty and choledochoduodenostomy for benign biliary obstructions

Both sphincteroplasty and choledochoduodenostomy are valuable for choledocholithiasis, stenosis of the terminal bile duct, and occasional cases of pancreatitis. Selection of patients, technical details, and advantages and limitations of both operative procedures are presented. In a personal series of 600 benign biliary operations 73 patients had a sphincteroplasty or choledochoduodenostomy. Sixty of these had a sphincteroplasty without operative mortality, serious complication, or recurrence of biliary problems although 5 still have pain. A positive morphine-prostigmine test was a prime indication for surgery in these 5 patients. The evocative tests are now negative. Thirteen patients had a choledochonduodenostomy without mortality or significant complication. Twelve are symptom free but one has a "sump syndrome." Sphincteroplasty has been preferred because it gives dependent drainage, direct inspection of the ampullary area, and facilitates removal of impacted stones and debris. It is not always applicable and choledochoduodenostomy has been chosen in elderly poor risk patients or in those with pancreatic inflammation or periampullary duodenal diverticula. Both operations have specific advantages and limitations such that the surgeon should not use one to the exclusion of the other.