Br. J. Surg. Vol. 66 (1979) 389-391
Exploration of the common bile duct: a comparative study K. D . V E L L A C O T T A N D P. H. P O W E L L * SUMMARY
The results of a retrospective comparative study of 122 patients who underwent explorations of the common bile duct in a district general hospital over a 5-year period are presented. Seventy-eight patients had a supraduodenal choledochotomy, 32 had a transduodenal sphincterotorny and I2 had a combination of both procedures. Particular attention was paid to postoperative complications in relation to the grade of the surgeon performing the operation and also to the age of the patient. A total of 78 (64per cent)patients had definite stones in the common bile duct. Of thesepatients, 7 (9per cent) were subsequently shown to have retained stones, all having been operated on by registrars. Registrars also did more negative explorations than consultants. Nine patients (7.4 per cent) died, all but 1 of them being over the age of 70 and 4 of them having had a combined procedure. We conclude that transduodenal exploration should be avoided in patients over 70, particularly when added to a supraduodenal exploration.
CHOLECYSTECTOMY is the commonest elective abdominal operation performed in this country and between 10 and 49 per cent of these patients will have their common bile ducts explored (Le Quesne, 1964). The usual method of exploring the common bile duct has been by a supraduodenal approach, opening the duct as it lies in the free border of the lesser omentum with subsequent closure around a T tube, and this remains the method of choice for most British surgeons. This method, however, is not without complications and attention has been drawn from time to time t o its disadvantages, the major one being the relatively high incidence of retained stones, which varies between 4 and 22 per cent in different series (Way et al., 1972, Glenn, 1974; Corlette et al., 1978). It is also impossible to see the sphincter, and attempted blind dilatation may lead to a false passage. A second method of exploration was first described by Kocher in 1895 and it involves a transduodenal approach with a sphincterotomy of the duodenal papilla. Advocates of this method have shown a lower incidence of retained stones, no evidence of papillary stenosis after the procedure and, though there is reflux in many cases, this was not associated with postoperative cholangitis (Peel et al., 1975). Critics of the method have suggested a higher incidence of pancreatitis after sphincterotomy. A third method involves a combination of both approaches and is usually used where a supraduodenal approach has failed, owing to either a stricture at the lower end of the bile duct or an impacted stone. Recently it has been suggested that this combined approach should be used electively in certain selected patients who have multiple stones, residual stones after previous surgery, stricture at the papilla or impacted stones in the ampullary region (Aubrey and
Edwards, 1978). The advantage of using the method electively would be that a protracted attempt at a supraduodenal exploration could be avoided. This retrospective study was conducted in a district general hospital to compare the results after these three procedures and to relate the results t o the grade of the surgeon performing the operation. Patients and methods Cheltenham General Hospital is a district hospital serving a population of 200 000. There are three general surgeons, two of whom use the supraduodenal method of exploration while the other uses the transduodenal approach preferentially. Each expected their junior staff to carry out similar procedures. During the 5-year period from 1973 to 1977; 630 cholecystectomies were performed. Of these patients, 126 (20 per cent) underwent explorations of the common bile duct. Four of these patients were lost to follow-up, so that 122 patients are included in the study. Patients were seen routinely in the outpatients department after their operations and those with persisting symptoms had intravenous cholangiograms. Those patients who were symptom-free, and had been discharged from the outpatients clinic, were not followed up further. The operations were carried out in a standard manner and all the patients had peroperative cholangiography. There were 90 patients who had supraduodenal explorations, including those who had an additional sphincterotomy, and these were all closed around a T tube. Fifty of the patients had on-table postexploratory T tube cholangiograms and a11 90 had T tube cholangiograms on or about the tenth postoperative day. Both types of exploration were drained postoperatively. Choledochoduodenostomy was not performed. The number of cases in each group and the grade of surgeon performing the operation are shown in Table I. The ages of the patients ranged from 19 to 91 years with a mean age of 66. Women predominated in the ratio of 2 : 1 (female 84, male 38).
Table I: NUMBERS IN EACH GROUP AND GRADE OF SURGEON PERFORMING THE OPERATION Supraduodenal Transduodenal Combined Consultant 40 21 6 Registrar 38 I1 6 Total 78 32 12
Results Of the 122 patients explored, 78 (64 per cent) had stones in the common bile duct, giving an incidence of 12 per cent for the whole group of 630 cholecystectomies. Twenty-seven (61 per cent) of the remaining 44 operations where no stones were found were performed by registrars. Reasons for these negative explorations were dilated common bile ducts with a history of previous jaundice (14), no flow into the duodenum (15) and filling defects seen on operative cholangiography (15). Three patients in whom no stones were found in the common bile duct died. One had a transduodenal sphincterotomy for a very dilated common bile duct and the other 2 had a
* Cheltenham General Hospital. Correspondence to: K. D. Vellacott, NottinghamCity Hospital.
390
K. D. Vellacott and P. H. Powell
All except one of these patients was over 70 years of age (Table I I ) . Four patients who had advanced obstructive jaundice died of renal failure. The mean Cause of death ages for each group and the mortality in patients over 83 TD Reg. Ascending cholangitis Cons. Cirrhosis and renal failure 70 is shown in Table III. 85 TD None of the 12 patients in the combined group had 91 SD Reg. Cardiac failure this procedure performed as an elective operation. 77 TD & SD Cons. Hepato-renal failure Reg. Myocardial infarction 74 TD Eleven patients had initial supraduodenal exploraReg. Septicaemia 75 SD tions, 4 patients having impacted stones which could 70 TD & SD Cons. Pancreatitis and not be removed from above, and 7 had tight papillae pulmonary embolus which would not permit the passage of a small dilator 58 TD & SD Cons. Hepato-renal failure from above and showed no flow into the duodenum 74 TD & S D Reg. Hepato-renal failure on cholangiography. The remaining patient had an TD, Transduodenal; SD, supraduodenal. attempted transduodenal exploration by a registrar, but the papilla could not be found and a supraduodenal exploration was performed. Table 111: MEAN AGES IN EACH GROUP AND MORTALITY IN PATIENTS OVER 70 There were 6 retained stones in the supraduodenal group (7.7 per cent) and 1 retained stone in the SD TD T D & S D combined group demonstrated by postoperative T 63 67 67 Mean age (yr) tube cholangiography (TabEe 1Y). No patient in the 8 3 Patients over 70 17 transduodenal group has developed any symptoms to No. of deaths in patients over 70 2 3 3 suggest retained stones. Five of the patients had onSD, Supraduodenal; TD, transduodenal. table post-exploratory T tube cholangiography at which the retained stones were not detected. RetroTable IV: COMPLICATIONS spective examination of these films showed the stones to have been demonstrated in 2 cases. One patient who SD TD Combined did not have an on-table T tube cholangiogram had an ( n = 78) (n= 32) ( n = 12) initial negative exploration. Two patients had their rePancreatitis 0 0 2 tained stones removed by further surgery. One patient Biliary leak 1 0 3 had an endoscopic sphincterotomy but developed a Retained stone 6 0 1 duodenal perforation and died after further surgery. Septicaemia 2 0 0 Renal failure 0 1 3 The remaining 4 patients have developed no symptoms Ascending cholangitis 1 1 0 from their retained stones and are being kept under DVT 1 0 0 regular review as outpatients. If the negative exploraPulmonary embolism 0 0 1 tions are excluded, the incidence of retained stones Intra-abdominal abscess 0 1 0 in this study is 7 out of 78 operations (9 per cent). Wound infection 14 6 1 Wound infection was defined as the presence of pus Myocardial infarction 0 1 0 and there was an overall incidence of 18.2 per cent. SD, Supraduodenal; TD, transduodenal. There was no significant difference between the transduodenal and supraduodenal groups, as shown Table V: WOUND INFECTIONS in Table V. Prophylactic antibiotics were not used routinely. Operation No. % The incidence of wound infection was less in the Supraduodenal 14 18.4 Transduodenal 6 18.7 combined group but 3 of the patients in the group died within 1 week. 1 9.1 Combined There was also no significant difference in the length of hospital stay between the supraduodenal Table VI: LENGTH OF STAY IN HOSPITAL and transduodenal group, but this was considerably longer in the combined group (Table VI). Ooeration Days
Table 11: MORTALITY Age Grade of (yr) Operation surgeon
Supraduodenal Transduodenal Combined
15
16 19
combined procedure for apparent papillary stenosis. All 3 patients were jaundiced. I n the 504 patients who had a cholecystectomy without exploration of the common bile duct, there were 5 deaths (a mortality of 1 per cent); in the group of 122 patients studied there were 9 deaths (a mortality of 7.4 per cent). If the deaths of patients who had negative explorations are taken separately, then the mortality in the explored group with stones was 6 out of 78 (7.6 per cent) and in those with no stones in the ducts, 3 out of 44 (6-8 per cent). There were 2 (2.5 per cent) deaths in the supraduodenal group, 3 (9.6 per cent), in the transduodenal group and 4 (33.3 per cent) in the combined group.
Discussion The exploration rate in this study was exactly 20 per cent and there was a very high mortality and morbidity in those patients who underwent a combined supraduodenal and transduodenal exploration. All of these patients except one initially had a supraduodenal exploration and was therefore subjected to protracted operations. It was in this group that the only 2 cases of pancreatitis occurred and the amount of instrumentation was probably responsible for this, though both patients had T tubes. Keighley and Graham (1973) found a high incidence of pancreatitis, after explorations of the common bile duct, particularly in those who had had a combined supraduodenal and transduodenal approach. Pancreatitis occurred in all 4 cases quoted by them. A much lower incidence of clinical pancreatitis has been found by other authors (Peel et a!., 1975; Aubrey and Edwards, 1978),
Exploration of the common bile duct though the serum amylase may be raised without symptoms. This study showed no cases of clinical pancreatitis in either the supraduodenal or transduodenal group. The grade of the surgeon performing the operation did not affect the mortality or morbidity in any group except in the case of retained stones, registrars having performed all of these operations. This would suggest that experience does play an important part in preventing this major complication of explorations of the common bile duct. Most general surgeons are unlikely to explore more than 12 common bile ducts in a year, so that it will take several years to become fully experienced in the technique. Most retained stones can be detected on postexploratory T tube cholangiography at the time of operation. The fact that 5 of the 7 cases with retained stones in this study had had postexploratory T tube cholangiograms illustrates that cholangiography is not infallible and is often extremely difficult to interpret. Corlette et al. (1978) showed an alarmingly high incidence of retained stones of 22 per cent. On retrospective examination of the postexploratory T tube cholangiograms, Corlette and colleagues found that in 16 of the 22 cases the stones were shown by the radiographs at the time of operation, but were overlooked. However, the examination may not always reveal retained s:ones and ducts can be explored in the presence of a normal cholangiogram and stones found (Way et al., 1972). We were unable to demonstrate any significant complications attributable directly to T tube drainage. Ascending cholangitis occurred in 1 patient in the supraduodenal and 1 in the transduodenal group. However, there were 2 cases of septicaemia in the supraduodenal group (Table ZV). Chande and Devitt (1973) suggested primary closure of the choledochotomy as they had shown a higher morbidity in patients with T tubes. With increasing success in dissolving stories with solutions infused down T tubes (Gardner et al., 1975; Chary, 1977) or by removal with a modified Dormia basket (Christiansen et al., 1978), we feel that T tube drainage should still be used after supraduodenal explorations. Endoscopists are also obtaining good results in the treatment of stones in the common bile duct by endoscopic sphincterotomy and basket extraction. The mortality rate for the procedure can be as low as 1.4 per cent (Safrany, 1978). The mortality for patients over 70 years of age in the transduodenal and combined groups was very high. Johnson and Rains (1972) showed that in a series of 50 patients who had had a choledochoduodenostomy performed, 25 of whom were over 70, there were no postoperative deaths. Where exploration of the common bile duct by the supraduodenal method is proving difficult, and the operation likely to become prolonged, it would seem that a lower mortality could be obtained by doing a choledochoduodenostomy
391
preferentially rather than risking a transduodenal sphincterotomy. Our findings would suggest that any transduodenal exploration should be avoided over the age of 70. There was a surprisingly low incidence of thromboembolism, 1 case of deep vein thrombosis and 1 pulmonary embolus, though a proportion of the patients did receive low dose heparin treatment. In contrast, Keighley et al. (1976) showed a 12 per cent incidence of thromboembolism in patients with T tube drainage. Acknowledgements We would like t o thank M r P. Boreham, M r S . Haynes and Mr J. Fairgrieve, consultant surgeons, for permission to study the case records of their patients. We would also like to thank Mr C. B. Williams for his help in the preparation of this paper.
References and EDWARDS J. L. (1978) The Selective use Of combined supraduodenal and transduodenal exploration of the common bile duct. Br. J. Surg. 65, 246-251. CHANDE s. and DEVITT I. E. (1973) T-tubes, the surgical amulet after cboledochotomy. Surg. Gynecol. Obsret. 136, 100102. CHARY s. (1977) Dissolution of retained stones using heparin. Br. J. Surg. 64, 347-351. CHRISTIANSEN L. A., NIELSON 0. v. and EFSEN F. (1978) Nonoperative treatment of retained bile duct calculi in patients with a n indwelling T-tube. Br. J. Surg. 65, 55815584. CORLETTE M. B., SCHATZKI s. and ACKROYD F. (1978) Operative cholangiography and overlooked stones. Arch. Surg. 113, 729-734. GARDNER B., DENNIS c. R. and PATTI I. (1975) Current status of heparin dissolution of gallstones. Am. J. Surg. 130, 293295. GLENN F. (1974) Retained calculi within the biliary ductal system. Ann. Surg. 179, 528-537. JOHNSON A. G. and RAINS A. J. H. (1972) Choledochoduodenostomy. A reappraisal of its indications based on a study of 64 patients. Br. J. Surg. 59, 277-280. KEIGHLEY M. R. B., BURDEN D. w., BAUDELEY R. M. et al. (1976) Complications of supraduodenal choledochotomy: a comparison of three methods of management. Br. J . Surg. 63, 754-758. KEIGHLEY M. R. B. and GRAHAM N. G. (1973) The aetiology and prevention of pancreatitis following biliary tract operations. Bv. J . Surg. 60, 149-152. KOCHER T. (1895) Correspondenz. B1. Schweiz. Aertze 25, 193. LE QUESNE L. P. (1964) In: SMITH R. and SHERLOCK s. (ed.) Surgery of the Gallbladder and Bile Ducts. London, Butterworths, p. 122. PEEL A. L. G., BOURKE I. B., HERMON-TAYLOR I. et al. (1975) How should the common bile duct be explored? Ann. R . CON. Surg. Engl. 56, 124- 134. SAFKANY L. (1978) Endoscopic treatment of biliary tract diseases. Lancet 2, 983-985. WAY L. w., AIMIRAND w. H. and DUNPHY J. E. (1972) Management of choledocholithiasis. Ann. Surg. 176, 347-357.
AUBREY D. A.
Paper accepted 8 December 1978.
Exploration of the common bile duct: a comparative study K. D . V E L L A C O T T A N D P. H. P O W E L L * SUMMARY
The results of a retrospective comparative study of 122 patients who underwent explorations of the common bile duct in a district general hospital over a 5-year period are presented. Seventy-eight patients had a supraduodenal choledochotomy, 32 had a transduodenal sphincterotorny and I2 had a combination of both procedures. Particular attention was paid to postoperative complications in relation to the grade of the surgeon performing the operation and also to the age of the patient. A total of 78 (64per cent)patients had definite stones in the common bile duct. Of thesepatients, 7 (9per cent) were subsequently shown to have retained stones, all having been operated on by registrars. Registrars also did more negative explorations than consultants. Nine patients (7.4 per cent) died, all but 1 of them being over the age of 70 and 4 of them having had a combined procedure. We conclude that transduodenal exploration should be avoided in patients over 70, particularly when added to a supraduodenal exploration.
CHOLECYSTECTOMY is the commonest elective abdominal operation performed in this country and between 10 and 49 per cent of these patients will have their common bile ducts explored (Le Quesne, 1964). The usual method of exploring the common bile duct has been by a supraduodenal approach, opening the duct as it lies in the free border of the lesser omentum with subsequent closure around a T tube, and this remains the method of choice for most British surgeons. This method, however, is not without complications and attention has been drawn from time to time t o its disadvantages, the major one being the relatively high incidence of retained stones, which varies between 4 and 22 per cent in different series (Way et al., 1972, Glenn, 1974; Corlette et al., 1978). It is also impossible to see the sphincter, and attempted blind dilatation may lead to a false passage. A second method of exploration was first described by Kocher in 1895 and it involves a transduodenal approach with a sphincterotomy of the duodenal papilla. Advocates of this method have shown a lower incidence of retained stones, no evidence of papillary stenosis after the procedure and, though there is reflux in many cases, this was not associated with postoperative cholangitis (Peel et al., 1975). Critics of the method have suggested a higher incidence of pancreatitis after sphincterotomy. A third method involves a combination of both approaches and is usually used where a supraduodenal approach has failed, owing to either a stricture at the lower end of the bile duct or an impacted stone. Recently it has been suggested that this combined approach should be used electively in certain selected patients who have multiple stones, residual stones after previous surgery, stricture at the papilla or impacted stones in the ampullary region (Aubrey and
Edwards, 1978). The advantage of using the method electively would be that a protracted attempt at a supraduodenal exploration could be avoided. This retrospective study was conducted in a district general hospital to compare the results after these three procedures and to relate the results t o the grade of the surgeon performing the operation. Patients and methods Cheltenham General Hospital is a district hospital serving a population of 200 000. There are three general surgeons, two of whom use the supraduodenal method of exploration while the other uses the transduodenal approach preferentially. Each expected their junior staff to carry out similar procedures. During the 5-year period from 1973 to 1977; 630 cholecystectomies were performed. Of these patients, 126 (20 per cent) underwent explorations of the common bile duct. Four of these patients were lost to follow-up, so that 122 patients are included in the study. Patients were seen routinely in the outpatients department after their operations and those with persisting symptoms had intravenous cholangiograms. Those patients who were symptom-free, and had been discharged from the outpatients clinic, were not followed up further. The operations were carried out in a standard manner and all the patients had peroperative cholangiography. There were 90 patients who had supraduodenal explorations, including those who had an additional sphincterotomy, and these were all closed around a T tube. Fifty of the patients had on-table postexploratory T tube cholangiograms and a11 90 had T tube cholangiograms on or about the tenth postoperative day. Both types of exploration were drained postoperatively. Choledochoduodenostomy was not performed. The number of cases in each group and the grade of surgeon performing the operation are shown in Table I. The ages of the patients ranged from 19 to 91 years with a mean age of 66. Women predominated in the ratio of 2 : 1 (female 84, male 38).
Table I: NUMBERS IN EACH GROUP AND GRADE OF SURGEON PERFORMING THE OPERATION Supraduodenal Transduodenal Combined Consultant 40 21 6 Registrar 38 I1 6 Total 78 32 12
Results Of the 122 patients explored, 78 (64 per cent) had stones in the common bile duct, giving an incidence of 12 per cent for the whole group of 630 cholecystectomies. Twenty-seven (61 per cent) of the remaining 44 operations where no stones were found were performed by registrars. Reasons for these negative explorations were dilated common bile ducts with a history of previous jaundice (14), no flow into the duodenum (15) and filling defects seen on operative cholangiography (15). Three patients in whom no stones were found in the common bile duct died. One had a transduodenal sphincterotomy for a very dilated common bile duct and the other 2 had a
* Cheltenham General Hospital. Correspondence to: K. D. Vellacott, NottinghamCity Hospital.
390
K. D. Vellacott and P. H. Powell
All except one of these patients was over 70 years of age (Table I I ) . Four patients who had advanced obstructive jaundice died of renal failure. The mean Cause of death ages for each group and the mortality in patients over 83 TD Reg. Ascending cholangitis Cons. Cirrhosis and renal failure 70 is shown in Table III. 85 TD None of the 12 patients in the combined group had 91 SD Reg. Cardiac failure this procedure performed as an elective operation. 77 TD & SD Cons. Hepato-renal failure Reg. Myocardial infarction 74 TD Eleven patients had initial supraduodenal exploraReg. Septicaemia 75 SD tions, 4 patients having impacted stones which could 70 TD & SD Cons. Pancreatitis and not be removed from above, and 7 had tight papillae pulmonary embolus which would not permit the passage of a small dilator 58 TD & SD Cons. Hepato-renal failure from above and showed no flow into the duodenum 74 TD & S D Reg. Hepato-renal failure on cholangiography. The remaining patient had an TD, Transduodenal; SD, supraduodenal. attempted transduodenal exploration by a registrar, but the papilla could not be found and a supraduodenal exploration was performed. Table 111: MEAN AGES IN EACH GROUP AND MORTALITY IN PATIENTS OVER 70 There were 6 retained stones in the supraduodenal group (7.7 per cent) and 1 retained stone in the SD TD T D & S D combined group demonstrated by postoperative T 63 67 67 Mean age (yr) tube cholangiography (TabEe 1Y). No patient in the 8 3 Patients over 70 17 transduodenal group has developed any symptoms to No. of deaths in patients over 70 2 3 3 suggest retained stones. Five of the patients had onSD, Supraduodenal; TD, transduodenal. table post-exploratory T tube cholangiography at which the retained stones were not detected. RetroTable IV: COMPLICATIONS spective examination of these films showed the stones to have been demonstrated in 2 cases. One patient who SD TD Combined did not have an on-table T tube cholangiogram had an ( n = 78) (n= 32) ( n = 12) initial negative exploration. Two patients had their rePancreatitis 0 0 2 tained stones removed by further surgery. One patient Biliary leak 1 0 3 had an endoscopic sphincterotomy but developed a Retained stone 6 0 1 duodenal perforation and died after further surgery. Septicaemia 2 0 0 Renal failure 0 1 3 The remaining 4 patients have developed no symptoms Ascending cholangitis 1 1 0 from their retained stones and are being kept under DVT 1 0 0 regular review as outpatients. If the negative exploraPulmonary embolism 0 0 1 tions are excluded, the incidence of retained stones Intra-abdominal abscess 0 1 0 in this study is 7 out of 78 operations (9 per cent). Wound infection 14 6 1 Wound infection was defined as the presence of pus Myocardial infarction 0 1 0 and there was an overall incidence of 18.2 per cent. SD, Supraduodenal; TD, transduodenal. There was no significant difference between the transduodenal and supraduodenal groups, as shown Table V: WOUND INFECTIONS in Table V. Prophylactic antibiotics were not used routinely. Operation No. % The incidence of wound infection was less in the Supraduodenal 14 18.4 Transduodenal 6 18.7 combined group but 3 of the patients in the group died within 1 week. 1 9.1 Combined There was also no significant difference in the length of hospital stay between the supraduodenal Table VI: LENGTH OF STAY IN HOSPITAL and transduodenal group, but this was considerably longer in the combined group (Table VI). Ooeration Days
Table 11: MORTALITY Age Grade of (yr) Operation surgeon
Supraduodenal Transduodenal Combined
15
16 19
combined procedure for apparent papillary stenosis. All 3 patients were jaundiced. I n the 504 patients who had a cholecystectomy without exploration of the common bile duct, there were 5 deaths (a mortality of 1 per cent); in the group of 122 patients studied there were 9 deaths (a mortality of 7.4 per cent). If the deaths of patients who had negative explorations are taken separately, then the mortality in the explored group with stones was 6 out of 78 (7.6 per cent) and in those with no stones in the ducts, 3 out of 44 (6-8 per cent). There were 2 (2.5 per cent) deaths in the supraduodenal group, 3 (9.6 per cent), in the transduodenal group and 4 (33.3 per cent) in the combined group.
Discussion The exploration rate in this study was exactly 20 per cent and there was a very high mortality and morbidity in those patients who underwent a combined supraduodenal and transduodenal exploration. All of these patients except one initially had a supraduodenal exploration and was therefore subjected to protracted operations. It was in this group that the only 2 cases of pancreatitis occurred and the amount of instrumentation was probably responsible for this, though both patients had T tubes. Keighley and Graham (1973) found a high incidence of pancreatitis, after explorations of the common bile duct, particularly in those who had had a combined supraduodenal and transduodenal approach. Pancreatitis occurred in all 4 cases quoted by them. A much lower incidence of clinical pancreatitis has been found by other authors (Peel et a!., 1975; Aubrey and Edwards, 1978),
Exploration of the common bile duct though the serum amylase may be raised without symptoms. This study showed no cases of clinical pancreatitis in either the supraduodenal or transduodenal group. The grade of the surgeon performing the operation did not affect the mortality or morbidity in any group except in the case of retained stones, registrars having performed all of these operations. This would suggest that experience does play an important part in preventing this major complication of explorations of the common bile duct. Most general surgeons are unlikely to explore more than 12 common bile ducts in a year, so that it will take several years to become fully experienced in the technique. Most retained stones can be detected on postexploratory T tube cholangiography at the time of operation. The fact that 5 of the 7 cases with retained stones in this study had had postexploratory T tube cholangiograms illustrates that cholangiography is not infallible and is often extremely difficult to interpret. Corlette et al. (1978) showed an alarmingly high incidence of retained stones of 22 per cent. On retrospective examination of the postexploratory T tube cholangiograms, Corlette and colleagues found that in 16 of the 22 cases the stones were shown by the radiographs at the time of operation, but were overlooked. However, the examination may not always reveal retained s:ones and ducts can be explored in the presence of a normal cholangiogram and stones found (Way et al., 1972). We were unable to demonstrate any significant complications attributable directly to T tube drainage. Ascending cholangitis occurred in 1 patient in the supraduodenal and 1 in the transduodenal group. However, there were 2 cases of septicaemia in the supraduodenal group (Table ZV). Chande and Devitt (1973) suggested primary closure of the choledochotomy as they had shown a higher morbidity in patients with T tubes. With increasing success in dissolving stories with solutions infused down T tubes (Gardner et al., 1975; Chary, 1977) or by removal with a modified Dormia basket (Christiansen et al., 1978), we feel that T tube drainage should still be used after supraduodenal explorations. Endoscopists are also obtaining good results in the treatment of stones in the common bile duct by endoscopic sphincterotomy and basket extraction. The mortality rate for the procedure can be as low as 1.4 per cent (Safrany, 1978). The mortality for patients over 70 years of age in the transduodenal and combined groups was very high. Johnson and Rains (1972) showed that in a series of 50 patients who had had a choledochoduodenostomy performed, 25 of whom were over 70, there were no postoperative deaths. Where exploration of the common bile duct by the supraduodenal method is proving difficult, and the operation likely to become prolonged, it would seem that a lower mortality could be obtained by doing a choledochoduodenostomy
391
preferentially rather than risking a transduodenal sphincterotomy. Our findings would suggest that any transduodenal exploration should be avoided over the age of 70. There was a surprisingly low incidence of thromboembolism, 1 case of deep vein thrombosis and 1 pulmonary embolus, though a proportion of the patients did receive low dose heparin treatment. In contrast, Keighley et al. (1976) showed a 12 per cent incidence of thromboembolism in patients with T tube drainage. Acknowledgements We would like t o thank M r P. Boreham, M r S . Haynes and Mr J. Fairgrieve, consultant surgeons, for permission to study the case records of their patients. We would also like to thank Mr C. B. Williams for his help in the preparation of this paper.
References and EDWARDS J. L. (1978) The Selective use Of combined supraduodenal and transduodenal exploration of the common bile duct. Br. J. Surg. 65, 246-251. CHANDE s. and DEVITT I. E. (1973) T-tubes, the surgical amulet after cboledochotomy. Surg. Gynecol. Obsret. 136, 100102. CHARY s. (1977) Dissolution of retained stones using heparin. Br. J. Surg. 64, 347-351. CHRISTIANSEN L. A., NIELSON 0. v. and EFSEN F. (1978) Nonoperative treatment of retained bile duct calculi in patients with a n indwelling T-tube. Br. J. Surg. 65, 55815584. CORLETTE M. B., SCHATZKI s. and ACKROYD F. (1978) Operative cholangiography and overlooked stones. Arch. Surg. 113, 729-734. GARDNER B., DENNIS c. R. and PATTI I. (1975) Current status of heparin dissolution of gallstones. Am. J. Surg. 130, 293295. GLENN F. (1974) Retained calculi within the biliary ductal system. Ann. Surg. 179, 528-537. JOHNSON A. G. and RAINS A. J. H. (1972) Choledochoduodenostomy. A reappraisal of its indications based on a study of 64 patients. Br. J. Surg. 59, 277-280. KEIGHLEY M. R. B., BURDEN D. w., BAUDELEY R. M. et al. (1976) Complications of supraduodenal choledochotomy: a comparison of three methods of management. Br. J . Surg. 63, 754-758. KEIGHLEY M. R. B. and GRAHAM N. G. (1973) The aetiology and prevention of pancreatitis following biliary tract operations. Bv. J . Surg. 60, 149-152. KOCHER T. (1895) Correspondenz. B1. Schweiz. Aertze 25, 193. LE QUESNE L. P. (1964) In: SMITH R. and SHERLOCK s. (ed.) Surgery of the Gallbladder and Bile Ducts. London, Butterworths, p. 122. PEEL A. L. G., BOURKE I. B., HERMON-TAYLOR I. et al. (1975) How should the common bile duct be explored? Ann. R . CON. Surg. Engl. 56, 124- 134. SAFKANY L. (1978) Endoscopic treatment of biliary tract diseases. Lancet 2, 983-985. WAY L. w., AIMIRAND w. H. and DUNPHY J. E. (1972) Management of choledocholithiasis. Ann. Surg. 176, 347-357.
AUBREY D. A.
Paper accepted 8 December 1978.
