Surgical applications of sphincteroplasty and choledochoduodenostomy

The papilla of Vater is subject to a variety of abnormalities that include congenital anomalies, inflammation, neoplasms, fibrosis, and motor dysfunction. Some of these lesions are clinically obvious (such as cancer or an impacted gallstone) and require aggressive therapy in order to provide relief from pain or biliary-pancreatic ductal obstruction. Other lesions, such as stenosing papillitis, are more subtle and provide few clues to their existence except recurrent episodes of abdominal pain. I have focused my discussion on the relative indications for sphincteroplasty and choledochoduodenostomy in the management of benign lesions of the papilla, especially those related to gallstone disease. I prefer a choledochoduodenostomy for the management of recurrent common duct stones when the bile duct is enlarged (greater than 2 cm) and thick-walled. The opening should be at least 2 cm in length when the anastomosis is completed. I employ a long anterior sphincteroplasty (greater than 2 cm) with a transampullary septectomy when treating inflammatory or fibrosing lesions of the papilla of Vater which are associated with recurrent episodes of severe, chronic (more than 1 year) abdominal pain. There is currently no standardized way to diagnose these latter conditions, therefore, the approach is empirical, and should be used sparingly and with a high degree of caution.