The complications of elective choledochotomy in a prospective study of 116 patients with suspected intraduct calculi are reported. Management included T tube drainage (n = 59), primary closure of the bile duct (n = 29) and choledochoduodenostomy (n = 28). Septicaemia occurred in 12 patients (10%), with 1 death, and was unrelated to the type of operation. Thirty patients (26%) developed wound infection; this complication was more common after T tube drainage than the other procedures. Intra-abdominal abscess occurred in 3 patients only. Thrombo-embolism was recorded in 10 patients (9%), 7 of whom had an intraduct drain. Postoperative pancreatitis occurred in 5 patients (4%), with 2 deaths; a third of the patients in whom sphincteroplasty had been combined with supraduodenal choledochotomy developed this complication. Reoperation for stones was required in 3 patients with T tube; 3 patients developed a temporary biliary fistula after choledochoduodenostomy. The hospital stay was 9-5 days after primary closure, 14-0 days after choledochoduodenostomy and 16-8 days after T tube drainage. Wound sepsis (32%) and thrombo-embolism (12%) were more common in patients with bacterbilia than in patients where the bile was sterile at operation (13 and 3% respectively). Furthermore, wound sepsis, septicaemia and thrombo-embolism were reduced in patients who were given effective antibiotic cover.

This trial has investigated the value of gentamicin therapy in patients requiring biliary surgery. One hundred consecutive patients were randomly allocated to receive either gentamicin or no antibiotic. Post-operative infection was assessed by an independent observer. Cultures and gentamicin assays were performed on bile and blood sampled during and after operation. The minimum inhibitory concentrations of gentamicin were measured with isolated bacterial. In 80 per cent of patients biliary organisms were inhibited by 2 mug/ml of gentamicin. Twice this concentration was found in the serum at operation in 88 per cent, but in the bile in only 18 per cent. Nevertheless, gentamicin lowered the incidence of bacteria in the bile from 42 to 25 per cent. There was a reduction in wound sepsis from 21 to 6 per cent (P less than 0-05). Bacteriaemia was demonstrated in only 1 patient receiving gentamicin compared with 5 controls and 1 death occurred from endotoxaemia in the control group. These data suggest that gentamicin will reduce the morbidity of biliary surgery, particularly in patients in whom the bile is infected at operation.

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