Transduodenal sphincterotomy for stenosing papillitis and massive choledocholithiasis after Billroth II gastrectomy

Management of stenosing papillitis with massive cholecystodocholithiasis in patients previously operated upon with a Billroth II (B-II) type gastrectomy, is a challenging clinical problem. Endoscopic papillotomy in these patients has been described, but the success rate is low especially in the presence of a long afferent loop of the gastrojejunostomy and/or extensive adhesions. Long-standing common bile duct (CBD) stones lead to varying degrees of papillary stenosis. The latter could predispose to new stone formation because of the damaged CBD mucosa and varying degrees of stasis. In this paper we describe a simple method for intraoperative assessment of the papillary calibre and distensibility by correlation to the diameter of an inflated balloon catheter. This method has been used successfully in the management of five patients with no stone recurrence in the dilated CBD at follow-up.