Current problems in the surgical treatment of the biliary tract

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In a consideration of the current problems in the surgical treatment of biliary tract disease it has been emphasized that greater attention should be directed to diagnosis. The demonstration of gallstones or the failure of the gallbladder to be visualized by cholecystography does not exclude other conditions that may be the cause of the patient's symptoms. Common duct stones are one of the causes of the persistence or recurrence of symptoms following cholecystectomy. Intravenous cholangiography in those patients with a history indicative of or compatible with choledocholithiasis is suggested as an aid in securing evidence for exploration of the common duct in conjunction with cholecystectomy. Long-standing biliary tract disease is associated with many complications rarely or never seen in youth. Some of these, if unrecognized and as a result not treated, often end fatally. Biliary enteric fistula formation with gallstone ileus is an example. Its diagnosis and management is discussed as a condition that may be seen with increasing frequency as the old age fraction of our population increases. For the geriatric group data are presented that focus attention upon the need for precision management of patients undergoing surgical treatment for biliary tract disease. A realization of the hazards inherent in those individuals sixty-five years of age and over because of deficient function in one or more of the principal organs or systems should result in the preoperative preparation and exercising of caution in embarking upon therapeutic surgical procedures. Injury to the common duct in the course of the performance of cholecystectomy may be followed by consequences far more detrimental to the patient than the ordinary course of gallbladder disease. The technical steps believed to be most important in avoiding such inadvertent injury are presented in the description of retrograde cholecystectomy. Because biliary tract disease occurs in individuals of all ages and varies so much in its course, often giving rise to serious complications, it is looked upon by many as a complicated and somewhat confusing clinical condition. In an attempt to facilitate the recognition of the disease in any of its various stages, phases and associated developments, a simple classification for descriptive purposes is presented. This is based upon the morphology and course of disease rather than upon the grouping of patients according to age, sex or physical habitus.