Kocher's perampullary approach for common bile-duct calculi

Abstract

Supraduodenal choledochotomy for common bileduct stones carries the risk of biliary leakage, a predilection to stricture, and no certainty that all the stones are removed. Stones left behind after the first exploration and new stones formed later require secondary surgery, which is often difficult and has an even greater risk of serious complications. Perampullary exploration, on the other hand, does not carry an increased initial risk of death or of the complications of biliary fistulae and retained stones of which none occurred in this series. Late complications of stricture and secondary unpassable stones similarly did not occur. Neither method is free from the risk of postoperative pancreatitis (1 per cent in this series), but there is no evidence that perampullary exploration carries a greater risk than supraduodenal exploration. Even so, it is considered wise to give propantheline for 72 hours after perampullary exploration to reduce this risk. It has been suggested that a wide, poorly competent, distal common‐duct orifice might predispose to ascending cholangitis. No case in this series developed such cholangitis, nor has any case developed stenosis at the sphincteroplasty which might encourage cholangitis. In fact, in the 3 cases that came to post‐mortem examination at intervals of 2 and 3 years the sphincteroplasties were still widely patent. Boulter (1961) suggested that sphincterotomy increased the flow of bile in the physiological pressure range and thus might be an additional benefit from the procedure.

The selective use of combined supraduodenal and transduodenal exploration of the common bile duct

“…Complications relating to the duodenotomy-namely obstruction, fistulation and associated abscess formation-have been well documented (Shieber, 1962;Menguy, 1965;Kourias and Tierris, 1966;Rothwell-Jackson, 1968;Thomas et al, 1971). Moreover, the occurrence of severe and even fatal pancreatitis has seriously detracted from the popularity of sphincterotomy, despite the recognition that this complication can occur after any surgical procedure on the biliary tract, particularly if the operation is protracted and traumatic (Blatherwick and Pattison, 1954;Mahorner and Browne, 1955;Diffenbaugh and Strohl, 1956;Shieber, 1962;Rothwell-Jackson, 1968;Hardy, 1969;Keighley et al, 1969;Thomas et al, 1971 ;Hunter, 1972;Stuart and Hoerr, 1972;Carter, 1973). In the present series, serious complications were rare (Table ZZ).…”

“…In most large series the incidence of complications following transduodenal sphincterotomy has been high and perioperative mortality rates of approximately 5 per cent have been reported (Mahorner and Browne, 1955;Shieber, 1962;Rothwell-Jackson, 1968;Thomas et al, 1971;Hunter, 1972;Stuart and Hoerr, 1972;Carter, 1973). Complications relating to the duodenotomy-namely obstruction, fistulation and associated abscess formation-have been well documented (Shieber, 1962;Menguy, 1965;Kourias and Tierris, 1966;Rothwell-Jackson, 1968;Thomas et al, 1971).…”

“…However, transduodenal exploration of the common bile duct is a well-established procedure and was first described by McBurney in 1898. More recent reports have confirmed the value of this technique and its relative safety, and indeed some authors have advocated the transduodenal route as the primary method of exploration (Wright, 1960;Hardy and Davenport, 1969; Hunter, 1972;Carter, 1973;Peel et al, 1974). However, others have stressed the potential hazards of this technique, namely haemorrhagic pancreatitis, duodenal obstruction and duodenal fistulation (Shieber, 1962;Rains, 1969).…”