374BRITISH MEDICAL JOURNAL 15 NOVEMBER 1975 during endoscopic retrograde cholangiography. The first results of intraductal pressure measurements during endoscopic cannulation have been published.12 13 The return of laboratory values to normal and the disappearance of the complaints after papillotomy verified retrospectively our diagnosis of papillary stenosis.The contraindications for endoscopic papillotomy are identical to those for the similar surgical procedure-that is, (a) long stenoses of the bile duct; (b) a papilla situated at the edge of a duodenal diverticulum; and (c) when the position of the papillotome in the common bile duct is not completely certain. In the case of very large and impacted stones papillotomy may relieve obstruction but one must warn against enforced extraction.Ductal stones smaller than 10 mm in diameter will pass into the duodenum spontaneously after papillotomy (fig 7). We tried to remove larger stones immediately after the incision was made to prevent them getting wedged into the ampulla. Manipulation must be done with great care as bile duct perforations with the Dormia basket and Fogarthy catheter'" have been described.Initially we favoured removing all stones immediately after papillotomy, and we successfully removed gall stones in this way in 11 cases-a single stone from eight patients and two to four stones from three patients. The Dormia catheter used for this purpose, however, is far from an ideal tool. It often does not open completely or it may slide out between the stone and wall of the duct. To try and repeat the procedure is time-consuming and increases considerably the exposure to radiation. An instrument to crush the stones intraductally is needed. In later patients we found that after a papillotomy of adequate length even larger calculi passed spontaneously (fig 8). Recently we have attempted mechanical stone extraction only if a residual stone is still present atthe follow-up examination a week afterpapillotomy.We failed to remove the stones in 6 patients: in three of these two or three stones were removed and one could not be mobilised. It is remarkable that the jaundice in four patients with retained stones also disappeared after papillotomy. A free bile flow was observed once papillary stenosis was relieved, despite the residual stone. Apart from the inadequacy of the extractor the causes of failure were: a stone tightly adhering to the wall in two cases, a very large stone in two cases, and restenosis of the papillotomy opening in two cases.A Wochenschrift, 1974, 99, 2255. 6 Classen, M, Medical Tribune, 1973 P B, et al, Lancet, 1972, 1, 53. 9 Safrany, L, et al, Gastroenterological Endoscopy, 1973 Safrany, L, Acta Gastro-enterologica Belgica, 1973, 36, 711 Medical Journal, 1975, 4, 374-375 Summary A high incidence of unexpected metal sensitivity was found in patients with metal-to-metal (McKee) hip arthroplasties. Patients with metal-to-plastic (Charnley) prostheses had no greater incidence of metal sensitivity than a control group awaiting operat...
