Non-operative removal of bile duct stones by duodenoscopic sphincterotomy

Surgical exploration of the common bile duct carries considerable risks in elderly and frail patients. Peroral, fibreoptic duodenoscopy allows access to the papilla of Vater in sedated patients and the opportunity to perform a diathermy sphincterotomy for removal of bile duct stones. We have attempted sphincterotomy in 134 patients, most of whom had previously undergone cholecystectomy and had some contraindication to a further operation. Sphincterotomy was technically successful in 129 patients (96 per cent), and all duct stones were removed in 119 patients (92.5 per cent of successful sphincterotomies). The technique failed only once in 95 patients with stones less than 14 mm diameter. Immediate complications occurred in 10 patients, 3 of whom required emergency surgery; 1 patient died. Endoscopic diathermy sphincterotomy is a major therapeutic advance in the management of elderly and high risk patients with bile duct stones. No significant adverse effects have yet been revealed in follow-up studies. However, the possibility of long term complications dictates the need for caution in offering this procedure to young patients who are fit for reoperation.