Primary common bile duct closure after open exploration for choledocholithiasis

Abstract

Background: Choledocholithiasis is the second-most common complication of cholecystolithiasis, occurring in approximately 10-15% of patients. For choledocholithiasis, there are two methods for CBD exploration to extract stones: either endoscopically, by endoscopic retrograde cholangiopancreatography (ERCP) with or without sphincterotomy, or surgically, by an open or laparoscopic method Open CBD exploration has been the principal treatment in many hospitals and is still considered the gold standard for the removal of CBD stones. Following common bile duct (CBD) exploration and stone removal, the choice for closure of the incised bile duct lies between primary closure and T-tube drainage. There are many papers reported by different authors, which support the direct closure of the duct immediately after exploration. The aim ofthis study was to assess the clinical short-term results and benefits of primary closure of the common bile duct after open choledochotomy for CBD calculi in a developing country like Egypt. Methods: Between December 2010 and December 2013; 74 patients with a radiological evidence of common bile duct stones were admitted and treated at the Gastrointestinal Surgery Unit, Main Alexandria University Hospitalin whom the common bile duct diameter was equal to or larger than 8 mm. Those associated with distal CBD strictures, multiple intrahepatic calculi, or malignancy were excluded After approval of local ethics committees, all patients included in this study were informed well about the operative procedure and an informed written consent was obtained from every patient before carrying the procedure. All patients' data, surgical procedures, complications and follow-up details were collected and analyzed Results: CBD exploration and stone removal followed by primary closure was performed in all patients. The mean age of patients was 55.3 ±15.7 years {range, 37-75 years). Most of the patients presented with biliary colic (74%). Sixty-seven patients {90%) had concomitant gallstones as evident by preoperative abdominal ultrasound The mean diameter of CBD was 12.3 ±3.2mm {range, 8-27mm). Themaximumnumberofstoneswas 14. The total complication rate was 54% (4174) and included wound infection with delayed wound healing and bileleakage. One patient had a bile leakage that subsided on the third postoperative day. There was no post­ operative biliary obstruction, residual stones, cholangitis, pancreatitis, biliary peritonitis or intra-abdominal collections. The mean postoperative hospital stay was 4.2 ± 1 days. There was no perioperativemortality. The mean durationof follow-up was 10.8 ± 3.2 months {range, 4-18 months). There was no recurrence of CBD stones or stricture of bile ducts observed during the follow up period and postoperative ultrasound findings were normal. Conclusion: Primary closure of the CBD after open choledochotomy for choledocholithiasis is safe, feasible and effective with shorter hospital stays and lower costs.