Fatal complications in surgery for biliary calculi.

A retrospective review of the deaths in 2877 consecutive operations for biliary calculus disorders was directed at defining the high-risk factors in operations for stone disease. A correctable factor in biliary operative mortality relates to errors in differential diagnosis and iatrogenic technical errors that result in hemorrhage, anastomotic leaks, duodenal injuries, and the tardy recognition and treatment of postoperative intraabdominal sepsis. A less manageable problem is the patient over 70 with advanced heart disease and/or diabetes, who presents with acute biliary sepsis. The combination of circumstances puts the individual at great risk, albeit there is no present alternative to surgery.

Choledochoduodenostomy as an adjunct to choledocholithotomy.

An experience with 200 instances of choledochoduodenostomy validates the point of view that when the calculus-containing common bile duct measures 1.2 centimeters in internal diameter, choledochoduodenostomy is an excellent therapeutic and prophylactic procedure for the management of the existing and predicted complications of choledochlithiasis. It can be applied with a mortality that is not greater than that ordinarily associated with insertion of a T tube. Choledochoduodenostomy has the advantage of bypassing the obstructive factors distal to the anastomosis, especially with regard to recurrent or residual common bile duct stones, tubular stenosis of the transpancreatic portion of the common duct, stasis and sludge bile, primary soft stones and the stenosis and diverticula in the area of the vaterian segment.

Cholangiographic documentation of noncalculous acute biliary colic.

We obtained cholangiographic demonstration of noncalculous acute biliary colic associated with common bile duct dilation in a 46-year-old woman with a 9-year history of postprandial right upper quadrant pain. Hepatic plexus vagectomy and cholecystectomy completely relieved her symptoms, now for a 10-year follow-up period.

Surgical significance of the histopathology of the common bile duct.

Silver biopsies of the common bile duct were obtained from 15 patients with clinical and surgical evidence of cholangitis. The most pronounced histologic changes were edema, congestion, and marked mucous gland hypertrophy and hyperplasia. No ulceration, intramural abscess, or areas of necrosis were found. Clinical cholangitis is not associated with necrotizing changes in the duct wall. This fact is the histologic basis for satisfactory healing of choledochal enteric anastomoses performed in the presence of cholangitis.

Gallstone-linked tubular stenosis of the common bile duct.

The transpancreatic segment of the distal common bile duct can be extrinsically stenosed by a pure gallstone-linked pancreatic disorder. It has a specific roentgen configuration--long, tubular and smooth. In two instances it was associated with severe suppurative complications. Precholedochotomy cholangiography is required to identify such long segment benign tubular stenosis of the distal common bile duct as an indication for management alternatives and as a guide to judicious common bile duct exploration.

Vagotogenic cholecystitis.

Truncal vagotomy provokes acute cholecystitis in the stone-containing gallbladder of dogs. An apparently similar sequence has been fortuitously observed in three patients. These circumstances suggest that where cholelithiasis is encountered in a clinical situation in which truncal vagotomy is performed, cholecystectomy or stone removal and cholecystostomy be done as a synchronous adjunctive procedure.

The web factor in cholangitis.

Choledochoscopy demonstrates that stone-related suppurative cholangitis has the pathologic characteristics of a multiloculated intraductal abscess. The fibrin web compartmentalizes the duct, traps calculi, and limits spontaneous extrusion. The stones act as foreign bodies and stasis maintains the bacterobilia. This is the anatomic basis and rationale for early direct surgical drainage as the definite effective treatment.

Choledochoduodenostomy as an adjunct to choledocholithotomy.

Choledochoduodenostomy was performed in 100 patients for calculus related disease of the common bile duct. There were no significant early or late complications of the anastomotic procedure. The 3 per cent mortality was related to antecedent advanced liver disease in two instances and, in one instance, to intra-abdominal sepsis. The surgical bypass has the advantage of circumventing the retained stone problem or the sequelae of benign obstructive disease in the distal part of the choledochus. It permits postoperative roentgenographic and endoscopic evaluation of the anastomotic site. Cholangitis, blind segment disability and malfunction have not been seen with these indications and this technique. When the common bile duct is at least 1.4 centimeters wide, primary or secondary choledochoduodenostomy with a wide anastomosis has significant advantages over T-tube intubation in the therapeutic and prophylactic management of choledocholithiasis.

Varices of the common bile duct as a surgical hazard.

In the case of a 78-year-old woman with three common duct stones is reported. The most striking finding at operation, was extensive varices of the common duct. There was no evidence of varices elsewhere nor of an arteriovenous fistula. The varices are assumed to be idiopathic or a unique manifestation of a chronic cholangitic venous disorder. The situation, although unique, is readily recognized. Methods of management directed at avoiding intraoperative bleeding are suggested.

Nonanastomotic hepaticogastrostomy for palliative decompression.

A simple, low risk technique has been used in two patients with high malignant obstruction of the common hepatic bile duct for the creation of a biliary enteric fistula.