Kocher's perampullary approach for common bile-duct calculi.

Abstract

Abstract Supraduodenal choledochotomy for common bileduct stones carries the risk of biliary leakage, a predilection to stricture, and no certainty that all the stones are removed. Stones left behind after the first exploration and new stones formed later require secondary surgery, which is often difficult and has an even greater risk of serious complications. Perampullary exploration, on the other hand, does not carry an increased initial risk of death or of the complications of biliary fistulae and retained stones of which none occurred in this series. Late complications of stricture and secondary unpassable stones similarly did not occur. Neither method is free from the risk of postoperative pancreatitis (1 per cent in this series), but there is no evidence that perampullary exploration carries a greater risk than supraduodenal exploration. Even so, it is considered wise to give propantheline for 72 hours after perampullary exploration to reduce this risk. It has been suggested that a wide, poorly competent, distal common-duct orifice might predispose to ascending cholangitis. No case in this series developed such cholangitis, nor has any case developed stenosis at the sphincteroplasty which might encourage cholangitis. In fact, in the 3 cases that came to post-mortem examination at intervals of 2 and 3 years the sphincteroplasties were still widely patent. Boulter (1961) suggested that sphincterotomy increased the flow of bile in the physiological pressure range and thus might be an additional benefit from the procedure.