Management of Choledocholithiasis: Should We Remove the Bile Duct?

Retrieval of stone by endoscopic papillotomy, laparoscopic choledochotomy or open choledochotomy is the treatment of choice for choledocholithiasis. Published literature shows that the recurrence rate is 4% to 24% with existing method of treatment. We have treated 8 patients who admitted with recurrent choledocholithiasis in the department of Hepato-Biliary-Pancreatic and Liver Transplant Surgery, Bangabandhu Sheikh Mujib Medical University (BSMMU), Bangladesh in the period of January 2016 to December 2019. None had intrahepatic duct abnormality or stones. All patients underwent either ERCP stenting, open choledocholithotomy or both 16 to 84 months back. Management policy is designed and outcome is observed on these patients. There were 3 males and 5 females; age ranges 18 to 60 years. The common bile duct (CBD) diameter of all patient ranges from 15 to 24mm. The shape of CBD is different from normal variant; S shaped, saculated, grossly dilated with terminal narrowing. Considering the anatomical abnormality and recurrence of disease we have removed the abnormal part of common bile duct along with stones and the operation was completed by Roux-en-Y hepaticojejunostomy. All patients were completely symptom free for 6 to 48 months after surgery. Removal of abnormal part of common bile duct with reconstruction in the form of Roux-en-Y hepatico-jejunostomy may be considered for treating choledocholithiasis with abnormal CBD (abnormally dilated, abnormally shaped, angulated or sacculated) however, long-term follow up is required for final comment.

Evaluation of Preoperative Ultrasonography in Gall Stone Disease to Predict Technical Difficulties during Laparoscopic Cholecystectomy.

Laparoscopic cholecystectomy is the gold standard in the treatment of gallstones. This study was carried out to determine the technical difficulties that can be encountered during laparoscopic cholecystectomy and to evaluate the role of ultrasonography in identifying patients at risk of conversion returning to open surgery. The objective of this study was to evaluate the efficacy of preoperative ultrasonography in assessing technical difficulty faced during laparoscopic cholecystectomy in gallstone disease. This was an observational comparative study which was conducted in the Department of Surgery of Shaheed Suhrawardy Medical College & Hospital, Dhaka, Bangladesh from January 2016 to January 2017. A purposive sampling method was applied to select the study sample. A total of 160 patients were included this study. Data processing and analysis were done using SPSS (statistical package for social sciences), version 20. The summarized data were presented in the form of figures and tables with due statistical interpretation. In this study, there was a total of 160 cases, among which 90(56.25%) turned out to have undergone normal laparoscopic cholecystectomies. Seventy (43.75%) were difficult, among which 6(3.75%) were converted to open cholecystectomies. Among 160 patients, 120(75%) were female and 40(25%) were male. There is a total of 136/160 (85%) patients with gallbladder wall thickness <3mm and 24/160 (15%) patients >3mm. Among the 136 patients with gallbladder wall thickness <3mm, there was difficulty in holding the gallbladder in 28(25%) cases, 28(20.6%) had undergone gallbladder perforation, 32(23.5%) had undergone moderate bleeding and only 2(1.5%) had undergone severe bleeding. Among the 24 patients with gallbladder wall thickness >3mm, there was difficulty in holding the gallbladder in 22(91.7%) cases, 18(75%) had undergone gallbladder perforation, 18(75%) had undergone moderate bleeding and only 2(8.33%) had undergone severe bleeding. It shows a total of 124/160 (77.5%) patients with normal gall bladder, 26/160 (16.25%) patients with contracted gallbladder and 10/160 (6.25%) patients with distended gallbladder. Among the 124 patients with normal gallbladder, 16(12.9%) had undergone difficult Calot's dissection, 26(21%) had undergone difficult gallbladder bed dissection, 26(21%) had undergone moderate bleeding and none had undergone severe bleeding. Among 26 patients with contracted gallbladder, 20(76.9%) underwent difficult Calot's dissection, 24(92.3%) had undergone difficult gallbladder bed dissection, 18(69.2%) had undergone moderate bleeding and 4(15.4%) had undergone severe bleeding. Among 10 patients with distended gallbladder, 4(40%) underwent difficult Calot's dissection, 6(60%) underwent difficult gallbladder bed dissection, 6(60%) had undergone moderate bleeding and none had undergone severe bleeding. From this study, we conclude that preoperative ultrasonography is a good predictor of difficulty in laparoscopic cholecystectomy in the majority of cases and should be used as a screening procedure.