Duodenoscopic sphincterotomy is an established method for dealing with common bile duct stones and papillary stenosis. Occasionally even an experienced operator is unable to carry out a sphincterotomy, for instance in the presence of large peri-papillary diverticula or Billroth II gastrectomy. Most of these patients will be offered surgery--a few will refuse or be unfit for operation. One further therapeutic option is a combined approach involving a radiologist and endoscopist, in which percutaneous transhepatic insertion of a guide wire through the papilla, with or without balloon dilatation, is used to facilitate insertion of the sphincterotome by the endoscopist. This has been done successfully in 10 of 11 patients attempted, without significant complication.
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