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A total of 247 patients with a diagnosis of ampullary stenosis were treated by endoscopic sphincterotomy (EST). Through the study period from 1983 to 1990, 70% of patients had remission of all symptoms and 82% of patients had most symptoms ameliorated. Four times as many precuts were required for patients with ampullary stenosis compared with a similar number of patients with common bile duct stones. When retained common bile duct stones are ruled out, ampullary stenosis is the most common cause for recurrent episodes of 'billary-like-colie' in postcholecystectomy patients. Ampullary stenosis should not be dismissed as a possible diagnosis just because the bile duct is not dilated or stones or 'sludge' are not identified with medical imaging. The implications for the patient and the institution of an overnight stay, rather than a 5-to-10-day stay with 'open' surgery, add further impetus to continue with this approach.

The management of duodenal perforation associated with endoseopie sphineterotomy is controversial. Despite the fact that many patients recover without surgery, surgical opinion tends to favor immediate operation upon diagnosis since the mortality is high when sepsis is advanced. To refine the criteria for operative management, all duodenal perforations after endoseopie sphineterotomy over a 5-year period were studied. in a series of 464 consecutive enduscopic sphincterotomies, 8 duodenal perforations occurred; additionally, 4 patients with duodenal perforation were referred from elsewhere for management. Six patients were maqaged initially with nonoperative treatment (group I), and six underwent exploratory surgery upon diagnosis or hospital transfer (group II). One patient in group I was operated on 4 days after diagnosis. Of the seven surgically treated patients, three had repair of the duodenal perforation and drainage of the abscess or phlegmon, but four had no gross inflammation or visible duodenal perforation requiring repair at exploration. The elinieal features of abdominal pain with physical signs significantly correlated with operative findings of pus or phlegmon (p

It is believed that decreased contractility of the muscle of the gallbladder may result in the formation of gallstones. In prairie dogs it has been shown that sphincterotomy (incision into the muscles of the sphincter, or muscular opening, that controls the flow of bile from the gallbladder) prevents the formation of gallstones, possibly by preventing stagnation of bile in the gallbladder. A study was undertaken on prairie dogs to determine if this beneficial effect of sphincterotomy is directly due to diversion of bile or if the bile diversion maintains gallbladder contractility, thus preventing a condition conducive to gallstone formation. The animals were fed a high-cholesterol diet (a stimulus to gallstone formation). In the animals that underwent sphincterotomy and bile diversion, the effect of the high-cholesterol diet was reduced or prevented; operated animals who did not undergo these procedures showed decreased gallbladder muscle contraction and they developed gallstones. These findings suggest that performing bile diversion and sphincterotomy may prevent gallstones by avoiding reduced contractility of the gallbladder. By decreasing the amount of bile that would fill the gallbladder, the muscle is not stretched and maintains greater contractility. If this is also true in humans, sphincterotomy may result in reduced formation of gallstones by maintaining gallbladder contractility and the ability of the muscle to empty the gallstone-causing bile. Studies are needed to observe gallstone formation and gallbladder contraction in humans. (Consumer Summary produced by Reliance Medical Information, Inc.)

Reflux, or back-flow, of digestive juices from the duodenum (part of the small intestine) into the stomach has been associated with damage to the mucosal lining of the stomach; this reflux may occur following cholecystectomy (surgical removal of the gallbladder). The sphincter of Oddi (the muscles transversing the bile and pancreatic ducts as they enter the duodenum) is the main regulator of bile flow into the duodenum, and it is not known how its loss of function affects duodenogastric reflux. A study was undertaken to determine if there is a difference in bile reflux and gastric mucosal damage between patients who have had cholecystectomy with sphincteroplasty and those who have had cholecystectomy alone. Sphincteroplasty refers to surgery on the sphincter muscle, and is performed when there are stones in the common bile duct. There were 16 patients who underwent cholecystectomy with sphincteroplasty, 14 patients who underwent only cholecystectomy, and 10 normal controls. Bile reflux was evaluated by measuring total concentration of bile acids and concentrations of single bile acids in the stomach juice. There was a significant difference in bile reflux between groups; the patients who had sphincteroplasty had significantly more bile reflux than did the cholecystectomy-only group or the controls. Chronic atrophic (wasting) gastritis (inflammation of the stomach lining) was associated with sphincteroplasty, whereas superficial gastritis was more frequent in the cholecystectomy group. These findings suggest that cholecystectomy with sphincteroplasty may result in more duodenogastric reflux than cholecystectomy alone. Also, there may be a relationship between the amount of reflux and the severity of damage to the stomach lining. (Consumer Summary produced by Reliance Medical Information, Inc.)