|Year : 2016 | Volume
| Issue : 1 | Page : 29-32
Evaluation of primary repair of common bile duct in common bile duct stones
Mohamed A Abdel-Raheem, Abdelmonem A Mohamed, Emad A Ibrahim, Mohamed B Gaber
Surgery Department, Al-Azhar University, Assiut, Egypt
|Date of Submission||10-Nov-2015|
|Date of Acceptance||15-Dec-2015|
|Date of Web Publication||18-Apr-2016|
Mohamed A Abdel-Raheem
Surgery Department, Al-Azhar University, Assiut, Post code: 71111
Source of Support: None, Conflict of Interest: None
Despite advancements in gallbladder surgery with the introduction of endoscopic and laparoscopic techniques, many surgeons, especially in the developing world, still perform open cholecystectomy with common bile duct (CBD) exploration for choledocholithiasis.
Aim of the study
The purpose of the study was to report the outcomes of open CBD exploration without the use of T-tubes.
Materials and methods
A prospective study of open CBD exploration and primary closure was performed without T-tube drainage. Preoperative investigations, the surgical techniques, and perioperative outcomes were recorded.
Fifty patients had CBD exploration. In 45 patients this was performed by means of a supraduodenal choledochotomy, and in five of these patients free passage into the duodenum could not be achieved using catheters, irrigation, and dilators. These were completed with a choledochoduodenostomy.
In a limited resource setting, there is still a role for open CBD exploration and primary closure without the necessity of T-tubes and stents as evidenced by a good perioperative patient outcome.
Keywords: common bile duct, endoscopic and laparoscopic techniques, T-tubes
|How to cite this article:|
Abdel-Raheem MA, Mohamed AA, Ibrahim EA, Gaber MB. Evaluation of primary repair of common bile duct in common bile duct stones. Al-Azhar Assiut Med J 2016;14:29-32
|How to cite this URL:|
Abdel-Raheem MA, Mohamed AA, Ibrahim EA, Gaber MB. Evaluation of primary repair of common bile duct in common bile duct stones. Al-Azhar Assiut Med J [serial online] 2016 [cited 2017 Dec 17];14:29-32. Available from: http://www.azmj.eg.net/text.asp?2016/14/1/29/180459
| Introduction|| |
Gallstone disease occurs in 3–20% of the population worldwide. It may occur in the gallbladder or in the common bile duct (CBD) or common hepatic or the right or the left hepatic duct. About 15% of people with gallstone develop stones in the CBD .
Over the past two decades, the advancement in laparoscopic and endoscopic techniques has almost made open biliary surgery obsolete. Notwithstanding this, surgery is still indicated for large stone or when endoscopic retrograde cholangiopancreatography (ERCP) fails or when there is lack of training as well as equipment; many surgeons in the developing world are commonly required to perform open cholecystectomy and CBD exploration for choledocholithiasis. Even in the developed world, there are places where these resources may not be available .
The goal of treatment is to relieve the obstruction. In case of smaller stones, ERCP is suggested, and surgery is suggested for larger stone or when ERCP fails. Surgery for choledocholithotomy may be either open or laparoscopic. After the CBD exploration, stones are removed; the choice lies between primary duct closure and T-tube drainage .
The purpose of using T-tube drainage after open CBD exploration is for postoperative drainage of the bile duct to reduce edema and intraluminal pressure of CBD to visualize and extract retained bile duct stones .
Insertion of a T-tube increases postoperative morbidity, psychological trauma, prolonged hospital stay, and bed occupation irrespective of the surgical technique; the use of T-tubes for biliary drainage has been controversial to this date .
As early as 1965, Sawyers et al.  documented the advantages of primary closure of the CBD and recommended that routine use of a T-tube following CBD exploration be abandoned.
Open biliary surgery, CBD exploration, and drainage with primary closure of the CBD can be safe in experienced hands and is specifically useful in a limited resource .
Some authors found no significant difference in the morbidity or mortality between primary closure and T-tube drainage ,. Others found higher morbidity in terms of more biliary infection, discomfort from tube, and delayed hospital discharge .
The aim of our present study was to compare removal of primary CBD stone and primary closure of CBD with a drain tube in the right subhepatic region and discharge within 4 days and removal of CBD stone with T-tube drainage and subhepatic drainage, where the patient has to stay for 10–12 days.
| Materials and methods|| |
This was a prospective study conducted from January 2010 to December 2013 in the Department of Surgery at Al-Azhar University Hospital, Assiut Branch and Sohag Military Hospital. A total of 50 patients were explored for CBD stones with baseline investigations, which include blood test, renal function tests, chest radiography (P/A), ECG, serum bilirubin, serum alkaline phosphatase, Serum glutamic pyruvic transaminase (SGPT), and abdominal ultrasonography. When the location and cause of obstruction could not be diagnosed with ultrasonography then magnetic resonance cholangiopancreatography was performed. To rule out malignancy, contrast-enhanced computerized tomography was performed in selected cases. Patients proved with malignancy, renal failure, and other severe comorbidities were excluded from study.
A Kocher's subcostal incision was used. A longitudinal supraduodenal choledochotomy was performed. Any obvious stones were removed. An 8-Fr infant feeding tube was then passed distally and generous irrigation of the CBD was performed with normal saline. Use of this small tube allowed stones to float up alongside to be extruded at the choledochotomy. It also facilitated passage of the tube through the ampulla (if no obstruction was present).
Choledochtomy (Flow of irrigant with no return) was done to clear CBD. This was followed by dilating the sphincter of Oddi using Bake's dilator to 8- or 9-Fr caliber. If, however, a stone at the distal end could not be disimpacted, other options were carried out: a transduodenal sphincterotomy/sphincteroplasty or choledochoduodenostomy was performed. As free drainage of the bile into the duodenum is ensured by any of these options, no T-tube or stents were used. However, a 20-Fr subhepatic drain was placed in situ for 48 h postoperatively. Cholangiogram is performed to see distal clearance of CBD.
Primary closure was performed and the bile duct was closed with interrupted absorbable 3-0 suture and a subhepatic drain was kept for 48 h. All patients were given preoperative and postoperative antibiotics and follow-up was taken for the next 6 months.
| Results|| |
Of the 50 patients, 30 (60%) were female and 20 (40%) were male. The majority of patients were found to be between 40 and 60 years of age among the total range of age 31–70 years, with a median age of 45 years. An overall 80% of the patients had elevated bilirubin and hepatic enzymes in the preoperative period and 20% of the patients showed no obstruction apart from recurrent biliary colic. An overall 10% of the patients had cholangitis in the preoperative period.
The indications for CBD exploration included the following: preoperative jaundice in 30 patients, cholangitis in 10 patients, and asymptomatic CBD stones in 10 patients.
In all patients, cholecystectomy was performed along with CBD exploration. In 50 cases, the cystic duct was isolated and ligated before CBD exploration. In 45 cases, CBD exploration was performed through a supraduodenal choledochotomy; in five of these, free passage into the duodenum could not be achieved using catheters, irrigation, and dilators. These were completed by means of a choledochoduodenostomy.
All patients had a 20-Fr subhepatic drain in situ for 2 days postoperatively except of two cases, in which bile drainage persisted until the fourth postoperative day. The hospital length of stay ranged from 3 to 6 days, with a mean of 4 days. There were no complications such as postoperative biliary obstruction, cholangitis, and pancreatitis or biliary peritonitis.
Complication such as biliary leakage was seen in only one patient with primary closure, which was managed by keeping subhepatic drain for 5 days. Two patients developed wound infection as documented and pus was drained from the incision site. Respiratory infections required additional treatment. However, this had no relation to the method of drainage used. No patient in the study developed cholangitis. No patient died in the study.
| Discussion|| |
Our findings in this study is the good perioperative outcome for open biliary surgery without the usage of T-tubes and stents in a setting with minimal resources when ERCP and choledochoscopy are unavailable. Surgery is indicated for large stone or when ERCP fails.
In the modern minimally invasive approach era, the current standard protocol for the treatment of CBD stones is to clear and drain the CBD by means of ERCP, followed by laparoscopic cholecystectomy. However, these minimally invasive approaches are not widely practiced in many developing countries due to the lack of equipment and trained endoscopists. As mentioned earlier, even in the developed world, in rural settings, there is lack of equipment for these techniques .
ERCP was less successful compared with open surgery in CBD stone clearance and was associated with a higher mortality rate . There is also an increased recurrence rate of CBD stones following endoscopic removal .
Primary closure without a T-tube is safe and associated with a lower complication rate .
Because instrumentation of the CBD and maneuvers for stone extraction may cause edema to the papilla, leading to an increase in pressure inside the biliary tree, temporary postoperative biliary drainage is usually required and T-tube placement has been historically chosen as the drainage method of choice.
Those who advocate the use of a T-tube argue that it allows spasm or edema of sphincter to settle after the trauma of the exploration. Postoperative T-tube drainage has been used to prevent bile stasis, decompress the biliary tree, and minimize the risk for bile leakage. A T-tube has also provided an easy percutaneous access for cholangiography and extraction of retained stones. Despite these potential advantages, morbidity rates related to T-tube presence have been reported to be at a rate of 4–16%. The T-tube-related complications include accidental T-tube displacement leading to CBD obstruction, bile leakage, persistent biliary fistulas, excoriation of the skin, cholangitis from exogenous sources through the T-tube, and dehydration .
In addition, CBD stenosis has been reported as a long-term complication after T-tube removal. T-tubes require continuous management, thus restricting patient's activity because of the risk for dislodgement.
Because of the above-mentioned disadvantages of T-tube a second option for choledochotomy closure, which is primary closure of choledochotomy with placement of biliary endoprosthesis, was proposed. Biliary endoprosthesis, as with a T-tube, achieves biliary decompression, and published results have suggested that this leads to lower morbidity, shorter postoperative hospital stay, less postoperative discomfort, and earlier return to full activities, compared with T-tube placement .
Moreover, the presence of the endoprosthesis in the duodenal lumen makes postoperative ERCP easier, in the presence of residual CBD stones. However, the use of biliary endoprosthesis is not devoid of complications such as duodenal erosion, stent occlusion, ampullary stenosis, and distant stent migration, causing intestinal or colonic perforation .
Moreover, removal of biliary endoprosthesis requires second-stage endoscopic extraction. A third option for choledochotomy closure is primary closure without the use of T-tube or biliary endoprosthesis. Favorable short-term and long-term results have been published with this technique. This option avoids the morbidities related to the use of T-tube or biliary stents. In this study, no postoperative mortality occurred. The postoperative hospital stay and the operation time were shorter. However, our results do not match with those of some authors. A study noted higher complication and bile leakage rates after primary closure than those reported by this study, and an experimental study addressed the issue of stenosis following primary closure without some form of drainage. We need studies with longer follow-up period for the evaluation of ductal stenosis. At the end, according to the results of this early experience, primary closure did not increase the risk for bile leakage after the operation. Postoperative hospital stay and operation time were shorter, and the hospital expenses were lower. In addition, with primary closure, we could definitely avoid T-tube-related complications .
Open biliary surgery is not commonly performed. However, the fact remains that much of the equipment and training available to the developed world are still not available in the third-world setting. Many surgeons in limited resource settings are very well experienced with the open techniques; hence, in our opinion, open biliary surgery has its specific role to play in these settings. Interestingly , there are reports that the confidence level of surgical residents in the modern 'laparoscopic' era are low due to minimal exposure to open techniques and are not able to perform better in critical situations requiring an open approach .
| Conclusion|| |
Therefore, we can conclude that primary closure without external drainage after choledochotomy is feasible, safe, and cost-effective. However, randomized trials on a larger scale of patients and with a longer follow-up are necessary to address the issue of stenosis and other issues after primary closure.
Financial support and sponsorship
Conflicts of interest
There are no conflicts of interest.
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