Multiple bile duct stones: Comparison of two surgical techniques done at laparotomy.

##plugins.themes.academic_pro.article.sidebar##

Published Sep 15, 2017
Download
pdf
Vol. 94 No. 11 (2016): Issue Nov 2016

##plugins.themes.academic_pro.article.main##

Sami Daldoul
Aymen Mabrouk
Ikram Messoudi
Anis Ben Dhaou
Sofiène Sayari
Aymen Baccari
Faten Souai
Mounir Ben Moussa

Abstract

Background :Biliary lithiasis is the most common surgical disease in Tunisia. Multiple bile duct stones are one of his most rare complications.It poses real problems with the best therapeutic approach.

Aims: To analyze the results of conventional surgery for multiple bile duct stones by comparing two techniques: The choledochotomy for stoneextraction followed by external biliary drainage and biliary-enteric anastomosis, to identify and to analyze the factors influencing the therapeuticchoice.

Methods: During study period spanning 16 years, 137 choledochotomy were made for multiple bile duct stones. These patients had either acholedochotomy with stone extraction and then drained through a T-tube or a biliary-enteric anastomosis.

Results: Preoperative diagnosis of multiple bile duct stones has been made in 32.1 % of patients. Cholangiography was found in all casesmultiple bile duct stones and had demonstrated an association with intrahepatic stones in 18.2 %. External drainage by a Kehr drain wasperformed in 39.4 % and biliary-enteric anastomosis in 60.6 %. Univariate and multivariate analysis had identified three factors significantlyassociated with external drainage: age ≤ 65 years, bile duct diameter < 15 mm and the existence of a pronounced inflammatory reaction of thecholedochal wall. No factors had influenced the choice between different bilio-enteric anastomosis techniques. These three techniques did notdiffer from the post operative morbidity (p = 0.84) or mortality (p = 58).

Conclusion: Basing on the analysis of our series and the comparison with other series reported in the literature, we recommend biliary drainagewith a T-tube in young people under 65 years who have a little dilated bile duct, not exceeding 15mm. In patients aged over 65 years or thosewith a CBD dilated more than 15 mm, even with intrahepatic stones, in cases of distal bile duct stricture or periampullary diverticulum, biliaryentericanastomosis seems to be the safest technique.

Keywords:

Multiple bile duct stones, Common bile duct, Open surgery, Kehr, Bilio-enteric anastomosis

##plugins.themes.academic_pro.article.details##

References

  1. De Almeida AC, Aldeia FJ, Dos Santos NM, Gracias CW. Standard surgical approaches to primary choledocholithiasis-definitive versus temporary decompression. HPB Surg.1992; 6:35-49.
  2. Abdelmajid K, Houssem H, Rafik G, Jarrar MS, Fehmi H. Open Choldecho-Enterostomy for Common Bile Duct Stones: Is it Out of Date in Laparo-Endoscopic Era? N Am J Med Sci. 2013; 5:288-92.
  3. Shemesh E, Czerniak A, Bar-EL J, Schneabaum S, Bat L. Choledocholithiasis: a comparison between the clinical presentations of multiple and solitary stones in the common bile duct. Am J Gastroenterol. 1989; 84:1055-9.
  4. Huang SW, Lin CH, Lee MS, Tsou YK, Sung KF. Residual common bile duct stones on direct peroral cholangioscopy using ultraslim endoscope. World J Gastroenterol. 2013; 19: 4966-72.
  5. Tokumura H, Umezawa A, Cao H et al. Laparoscopic management of common bile duct stones: transcystic approach and choledochotomy. J Hepatobiliary Pancreat Surg. 2002; 9:206-12.
  6. Dindo D, Demartines N, Clavien PA. Classification of surgical complications: A new proposal with evaluation in a cohort of 6336 patients and results of a survey. Ann Surg. 2004; 240:205-13.
  7. Freitas ML, Bell RL, Duffy AJ. Choledocholithiasis: evolving standards for diagnosis and management. World J Gastroenterol. 2006; 12:3162-7.
  8. Desai R, Shokouhi BN. Common bile duct stones -their presentation, diagnosis and management. Indian J Surg. 2009; 71:229-37.
  9. Shojaiefard A, Esmaeilzadeh M, Khorgami Z, Sotoudehmanesh R, Ghafouri A. Assessment and treatment of choledocholithiasis when endoscopic sphincterotomy is not successful. Arch Iran Med. 2012; 15:275-8.
  10. Csendes A, Burdiles P, Diaz JC. Present role of classic open choledochostomy in the surgical treatment of patients with common bile duct stones. World J Surg. 1998; 22:1167-70.
  11. Moreaux J. Traditional surgical management of common bile duct stones: a prospective study during a 20-year experience. Am J Surg. 1995; 169:220-6.
  12. Shore JM. The prevention of residual biliary calculi. Calif Med. 1971; 114:1-6.
  13. Tantau M, Mercea V, Crisan D, et al. ERCP on a cohort of 2,986 patients with cholelitiasis: a 10-year experience of a single center. J Gastrointestin Liver Dis. 2013; 22:141-7.
  14. Targarona EM, Bendahan GE. Management of common bile duct stones: controversies and future perspectives. HPB. 2004; 6:140-3.
  15. Lygidakis NJ. Surgical approaches to recurrent choledocholithiasis. Choledocoduodenostomy versus T-tube drainage after cholédocotomie. Am J Surg. 1983; 145:636-9.
  16. Suc B, Fourtanier G, Escat J. Argument for choledochostomy, intraoperative endoscopy and external biliary drainage in the treatment of lithiasis of the common bile duct. A 15-year experience. Ann Chir. 1994; 48:905-10.
  17. Leggeri A, Roseano M, Trevisan G, Bortul M, DE Manzini N. Therapeutic development in common bile duct lithiasis. A propos of a 25-year experience. Chirurgie. 1993-1994; 119:552-6; discussion 556-7.
  18. Ambreen M, Shaikh AR, Jamal A, Qureshi JN, Dalwani AG, Memon MM. Primary closure versus T-tube drainage after open choledochotomy. Asian J Surg. 2009; 32:21-5.
  19. Ahmed I, Pradhan C, Beckingham IJ, Brooks AJ, Rowlands BJ, Lobo DN. Is a T-tube necessary after common bile duct exploration? World J Surg. 2008; 32:1485-8. 20- Zhu QD, Tao CL, Zhou MT, Yu ZP, Shi HQ, Zhang QY. Primary closure versus T-tube drainage after common bile duct exploration for choledocholithiasis. Langenbecks Arch Surg. 2011; 396:53-62.
  20. Zhu QD, Tao CL, Zhou MT, Yu ZP, Shi HQ, Zhang QY. Primary closure versus T-tube drainage after common bile duct exploration for choledocholithiasis. Langenbecks Arch Surg. 2011; 396:53-62.
  21. Targarona EM, Bendahan GE. Management of common bile duct stones: controversies and future perspectives. HPB (Oxford). 2004; 6:140-3.
  22. Daldoul S, Moussi A, Zaouche A. T-tube drainage of the common bile duct choleperitoneum: etiology and management. J Visc Surg. 2012; 149:e172-8.
  23. Huguier M, Houry S, Lacaine F, Pascal G. Choledochoduodenal anastomoses in biliary lithiasis. J Chir (Paris). 1986; 123:3-6.
  24. Uchiyama K, Onishi H, Tani M, et al. Long-term prognosis after treatment of patients with choledocholithiasis. Ann Surg. 2003; 238:97-102.
  25. Liu YB, Huang L, Xian ZY, Wang WD, Jian ZX. Causes of failure in choledochoscopic diagnosis and removal of gallstone. Di Yi Jun Yi Da Xue Xue Bao. 2005; 25:1577-8.
  26. Rettori R, Chabrun B, Lepinay P. Choledochoduodenal anastomosis in the treatment of biliary lithiasis. Chirurgie 1981; 107:475-6.
  27. Li ZF, Chen XP. Recurrent lithiasis after surgical treatment of elderly patients with choledocholithiasis. Hepatobiliary Pancreat Dis Int. 2007; 6:67-71.
  28. Malik AA, Rather SA, Bari SU, Wani KA. Long-term results of choledochoduodenostomy in benign biliary obstruction. World J Gastrointest Surg. 2012; 4:36-40.
  29. Engelberg M, Avrahami I, Erdman S, Reiss R. Choledochoduodenostomy--a useful procedure in the management of benign disorders of the biliary tract: a review of 53 cases. Am Surg. 1980; 46:344-8.
  30. Escudero-Fabre A, Escallon A JR, Sack J, Halpern NB, Aldrete JS. Choledochoduodenostomy. Analysis of 71 cases followed for 5 to 15 years. Ann Surg. 1991; 213:635-42.
  31. DE Aretxabala X, Bahamondes JC. Choledochoduodenostomy for common bile duct stones. World J Surg. 1998; 22:1171-4.
  32. Stefanini P, Carboni M, Patrassi N, Basoli A, DE Bernardinis G, Negro P. Roux-en-Y hepaticojejunostomy: a reappraisal of its indications and results. Ann Surg. 1975; 181:213-9.
  33. Qadan M, Clarke S, Morrow E, Triadafilopoulos G, Visser B. Sump syndrome as a complication of choledochoduodenostomy. Dig Dis Sci. 2012; 57:2011-5.
  34. Leppard WM, Shary TM, Adams DB, Morgan KA. Choledochoduodenostomy: is it really so bad? J Gastrointest Surg. 2011; 15:754-7.
  35. Parc R, Gillion JF, Malafosse M, Huguet C, Loygue. Results of choledoco-duodenostomy for common bile duct lithiasis. J Gastroenterol Clin Biol. 1986; 10:297-301.
  36. Degenshein GA. Choledochoduodenostomy: an 18 year study of 175 consecutive cases. Surgery. 1974; 76:319-24.
  37. Moesgaard F, Nielsen ML, Pedersen T, Hansen JB. Protective choledochoduodenostomy in multiple common duct stones in the aged Surg Gynecol Obstet. 1982; 154:232-4.
  38. DE Almeida AC, DOS Santos NM, Aldeia FJ. Choledochoduodenostomy in the management of common duct stones or associated pathology--an obsolete method? HPB Surg. 1996; 10:27-33.
  39. Vogt DP, Hermann RE. Choledochoduodenostomy, choledochojejunostomy or sphincteroplasty for biliary and pancreatic disease. Ann Surg. 1981; 193:161-8.
  40. Lasnier C, Kohneh-Shahri N, Paineau J. Biliary-enteric anastomosis malfunction: retrospective study of 20 surgical cases. Review of literature. Ann Chir. 2005; 130:566-72.
  41. Blankensteijn JD, Terpstra OT. Early and late results following choledochoduodenostomy and choledochojejunostomy. HPB Surg. 1990; 2:151-8.
  42. Mcsherry CK, Fischer MG. Common bile duct stones and biliary-intestinal anastomoses. Surg Gynecol Obstet. 1981; 153:669-76.
  43. DE Almeida AM, Cruz AG, Aldeia FJ. Side-to-side choledochoduodenostomy in the management of choledocholithiasis and associated disease. Facts and fiction. Am J Surg. 1984; 147:253-9.
  44. Rutledge RH. Sphincteroplasty and choledochoduodenostomy for benign biliary obstructions. Ann Surg. 1976; 183:476-87.
  45. Gupta BS. Choledochoduodenostomy: a study of 28 consecutive cases. Kathmandu Univ Med J (KUMJ). 2004; 2:193-7.
  46. Gurusamy KS, Samraj K. Primary closure versus T-tube drainage after open common bile duct exploration. Cochrane Database Syst Rev. 2007:CD005640.
  47. Joaquin A. Choledochoduodenostomy. Operative Techniques in General Surgery. 2000; 2: 304-10.
  48. Malik AA, Rather SA, Bari SU, Wani KA. Long-term results of choledochoduodenostomy in benign biliary obstruction. World J Gastrointest Surg. 2012; 4:36-40.