A comparative evaluation of T-tubne drainage vs primary Closure of common bile duct following choledochotomy for common bile duct

stones.

Introduction:

Choledocholilithiasis, presence of stones in common bile duct, can lead to cholongites, obstructive jaundice, repeated colic and pancreatitis . It requires urgent intervention. Treatment options include endoscopic retrieval of stones through ERCP. Though ERCP is the best procedure for CBD Stones; in selected group of patients, where ERCP failed or those patients who are willing for cholecystectomy and choledocholithotomy at one time, open or Laparoscopic management of CBD stone can be undertaken. In this study the common bile duct (CBD) was closed primarily after removal of stones. The results were good, the operative time and hospital stay was significantly lower. No significant bile leak occurred post operatively.

Material and Method:

From September 2006 to August 2010, 127 patients presented with common bile duct stones. 78 patients were referred to higher centrefor treatment by ERCP. In 5 patients ERCP failed and these were referred back for choledocholithotomy. 49 patients including those five who failed ERCP retrieval, were treated by choledocholithotomy; 27 by open exploration and T-tube drainage and 22 by open exploration and primary closure of CBD. There were19 to females and8 males in T-tube drainage group, where as in primar closure group there were 17 females and 5 males. S. Bilurubbin was raised in11 patients in T-tube drainage group ( mean of 2.6 mg/dl), whereas in 7 patients of primary closure group bilirubin was raised ( mean of 2.2 mg /dl ). After removal of stones from CBD, T-tbe was put and t-tube cholangiogram was done In T-tube group. Adrain was put in sub hepatic space which was rermoved after 24 to 72 hours. In primary closure group after removal of CBD stones, duct was visualized by 5 mm flexible choledoscope. After establishing complete clearance, choledocholitotomy incision was closed by interrupted 3-0 vicryl sutures. A drain was put in sub hepatic space, which was removed after 24-72 hours. Post operatively slight bile leak occured in 3 patients in t-tube gropup and in 4 patients I n primary closure group. In bothe the groups bile lastefor 24 to 48 hours and drain was removed after 72 hours.

Mean hospital stay was 14 days in T-tube drainage group . In primary closure group mean hospital stay was 3.8 days.

Discussion:

Though ERCP remains the main mode of treatment for common bile duct stone, followed by cholecystectomy for associated gall stones. In selected group of patients, patients where ERCP fails, or patients who agreed for on stage, cholecystectomy and CBD exploration can br undertaken. In this study open cholecystectomy & CBD exploration was done in 49 patient.In 27 of these patients after removing stones from CBD, T tube drainage was done and in22 patients primary closure of CBD was done. Post operatively bile leak was not significant in both the. Mean hospital stay was 14 days in Ttube drainage group whereas it was 3.8 days in primary closure group. Primary closure of CBD has been practiced by many surgeons. In 1919 Rilhter and Boshlander published their experience of primary closure of CBD. In 1942, Mirizzi et al showed good results in 31 patients under going primary results. He preferred transv erse incision in the duct. 1951 Mayo stated that after CBD exploration intraductal drainage was unnecessary. Lygidakis 1981, performed primary closure in 60 patients and 57 with T-tube drainage. Post operative bactraemia was noticed in 18 patients where T-tube was put and in 2 patients where primary closure was done. Gillat et al 1985 studeid the complications associated with T-Tube dramage in 36 patients; biliary leakage occured in 7 patients after T-tube removal; one patient developed biliary peritonitis and required reoperation. In our study there was no serious operative and post operative complications in T-tube drainage group, bile leak occurred in 3 patiernts which laste for not more than 72 hours. Primary closure of common bile duct after removal of stone can be safely carried out after establishing the complete clearance of CBD. M. K. Roy, Jan 2009 described use of rigid nephroscope to establish clearence of CBD during laparoscopic CBD exploration in 18 partients (Laparoscopic CBD exploration using a rigid nephroscop. Varbon O, 2010 Feb deseribed use of holicure for impacted CBD stone during laparoscpic CBD exploration.

El-decide AA. J. Gastromtest surgery 2010 may 4 (5) ; described primary closure of CBD after removal of stones. They concluded that post operative stay was significiantely lower after primary closure of CBD. It is also safe and cost effective. Tonk K. K. 2010 described 27 causes of open CBD exploration and 23 laparoscpic exploration of CBD for stone removal. They closed primary CBD after choledochtomy and concluded Lap CBD exploration and primary closure of CBD is safe.

Conclusion:

One stage Cholecystectomy and CBD exploration can be taken up in patients where ERCP failed or in those patients who are given this option and they agreed for it. CBD exploration and primary closure after removal of stones can safely be done after demonstration of complete patency of the CBD. Placement of T-tube after CBD exploration is not necessary; it can safely be closed primarily. It does not cause any signiificant complication and reduces hospital stay.

References :

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