Cholecystectomy and a simple technique of operative cholangiography

Benign disease of the common bile duct

The incidence of common bile duct (CBD) pathology in a group of patients with benign biliary disease (n = 505) was found to be 23.2 per cent. The spectrum included 111 patients (90.2 per cent) with CBD stones, 37 of whom (33.3 per cent) had no symptoms or findings pre-operatively indicating CBD involvement. Five patients had papillary stenosis, three had postoperative CBD strictures, one had a choledochal cyst and one had an external biliary fistula. Of the 100 CBDs measuring more than 10 mm in diameter, 90 harboured calculi. In the remaining 23 CBDs measuring less than 10 mm, calculi were present in 21. The presence of CBD calculi was demonstrated by intra-operative cholangiography in 49 patients. In the remaining patients (n = 74), the diagnosis of CBD pathology was made either by percutaneous transhepatic cholangiography, endoscopic retrograde cholangio-pancreatography, T-tube cholangiography or peroperative palpation. The surgical procedures performed included choledochotomy and T-tube drainage (n = 74), transduodenal sphincteroplasty (n = 27) and choledochoduodenostomy (n = 18). The overall mortality and morbidity of CBD exploration was 3.3 per cent and 24.4 per cent respectively, which was significantly greater than that for cholecystectomy alone (0.3 per cent and 8.6 per cent respectively). Transduodenal sphincteroplasty carried a much higher mortality (11 per cent) and morbidity (52 per cent) when compared with other procedures.

Routine or selective peroperative cholangiography

The routine use of peroperative (pre-exploration) cholangiography was prospectively studied in 433 consecutive patients undergoing elective cholecystectomy. Satisfactory peroperative cholangiography was achieved in 396 patients using a C-arm image intensifier with image retention facility. Clinical indications for exploration of the common bile duct were noted for each patient but the decision for choledochotomy was determined by the cholangiographic results. Two hundred and forty-nine (63 per cent) patients had no clinical indications for duct exploration and cholangiographic findings were all normal. Of the 147 patients with positive clinical criteria, 39 (9.8%) had abnormal cholangiograms and required exploration of the common bile duct. In three patients duct exploration was negative giving a false positive rate of 0.73 per cent. The use of the image intensifier allowed dynamic study during cholangiography and optimum evaluation of the duct system. The results support the view that peroperative cholangiography could be restricted to patients with clinical indications for exploration of the common bile duct.

Cholecystectomy in the elderly: a prospective study

The mortality and morbidity of 151 elderly patients (greater than 64 years of age) undergoing biliary surgery for benign disease were prospectively studied. The overall mortality was 3.3 per cent. This comprised a 0.77 per cent mortality in the elective group and a 19 per cent mortality in the emergency group. In spite of 77 per cent of the emergency group having a gangrenous gallbladder, a complication difficult to predict preoperatively, the majority of deaths were from cardiovascular disease. The overall incidence of common bile duct exploration was 36 per cent, which was similar in the elective and emergency groups. A comparison between the old (65-74 years) and the aged (over 74 years of age) revealed twice the number of emergency cases in the aged. Considering elective biliary surgery, there was no difference between the mortality, morbidity, or common bile duct exploration rate comparing the old with the aged. This suggests that elective biliary surgery is safe even in the aged.

Exploration of the common bile duct--the relevance of the clinical picture and the importance of peroperative cholangiography

A series of 500 cholecystectomies performed over a 7-year period was reviewed retrospectively. The reliability of preoperative clinical features such as jaundice and pancreatitis was assessed in determining the presence of choledocholithiasis, and was found to be of limited value. Investigations such as intravenous cholangiography and liver function tests were found also to be inaccurate in the detection of common duct stones as was the appearance of the duct at operation. The usefulness of the peroperative cholangiogram in the detection of common duct stones that would otherwise have been overlooked is emphasized. Common duct stones would have remained undetected in 25 per cent of patients with choledocholithiasis. Despite the use of routine peroperative cholangiography common duct stones were overlooked in 11.25 per cent of patients who underwent exploration.