Surgical audit of patients undergoing common bile duct exploration for stone

Abstract

One hundred and sixty-four patients operated on for calculus disease of the common bile duct during the period 1977-85 were followed in a special clinic; the attendance for follow-up at 1, 3, 5 and 7 years was 90, 74, 60 and 54 per cent respectively. Eleven patients died during the study period (6.7 per cent), none of the deaths being attributable to biliary tract disease. The overall incidence of retained calculus was 2.4 per cent (four patients), but no cases of retained calculi were recorded in the last 4 years of the study; in this period, with the advent of choledochoscopy and fluoroscopic cholangiography, the incidence of the supraduodenal compared with the transduodenal approach to the common bile duct increased significantly (P less than 0.001). Twenty-two of 56 patients (39 per cent) followed up for 5 years remained or became symptomatic after surgery, the majority of whom had underlying conditions unrelated to disease of the biliary or pancreatic tree. This specific follow-up clinic has been of value in the long-term audit of patients undergoing bile duct surgery for choledocholithiasis and it has verified that a change of policy from transduodenal to supraduodenal choledochotomy with preservation of the sphincter, and use of the choledochoscope and fluorocholangiography, produce better results.

Complications of biliary T‐tubes after choledochotomy

“…As demonstrated in the present study, individual surgeons experience few complications related to T‐tube use, and most published series report only a single case of biliary peritonitis requiring reoperation, 4–6,8,12 without examining other areas of morbidity. It is not surprising that T‐tube complications are considered rare; however, an incidence of biliary peritonitis requiring laparotomy of one case in 50 is similar to the results of the present study of 2.4%.…”

“…The type and incidence of complications identified in the present study are similar to that reported by Martin et al 3 and Gillatt et al 8 in much smaller series of choledochotomies. However, this is at variance with most of the published literature, which suggests T‐tube complications occur infrequently 4–7 . The present series represents the largest audit of choledochotomy with T‐tube insertion undertaken and has the advantage of being a near complete record review in a multi‐institutional setting.…”

“…Symptomatic bile leakage results in considerable morbidity and excessive hospital stay. Mortality arising from delayed management has been reported 2,6,7 . Recent publications have suggested placing a drain down the T‐tube tract after removal either routinely 22 or, in the case of the development of pain, 23 to prevent complications.…”

“…The use of T‐tubes can result in several complications. The most frequent of these is bile leakage after removal, which is reported to occur in 1–19% of cases 2–12 . If the tract is intact this creates a biliary fistula that usually resolves spontaneously.…”