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Open Common Bile Duct Exploration

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  • Clearance of biliary obstruction due to calculus disease if endoscopic techniques (eg, endoscopic retrograde cholangiopancreatography) are unavailable, have failed, or are not feasible due to patient anatomy or status.

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Transduodenal Sphincteroplasty

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  • Impacted stone at the ampulla of Vater.
  • Previous attempt at common bile duct exploration.
  • Most often performed at the time of cholecystectomy when common bile duct exploration has failed to clear a stone impacted in the distal common bile duct.

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Choledochoduodenostomy

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  • Unresectable malignant distal common bile duct obstruction, as a palliative procedure.
  • Benign strictures of the distal common bile duct.
  • Salvage drainage procedure in the presence of large primary stones or numerous stones in the distal common bile duct.

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Open Common Bile Duct Exploration

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Absolute

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  • None.

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Relative

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  • Previous biliary bypass.

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Transduodenal Sphincteroplasty

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Absolute

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  • None.

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Relative

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  • Fibrotic ampulla.
  • Inability to pass a 3-mm probe through the ampulla.
  • Abnormal-appearing ampulloduodenal junction on cholangiography.
  • Common bile duct diameter > 2 cm.
  • Long common bile duct stricture.

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Choledochoduodenostomy

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Absolute

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  • Duodenal obstruction.

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Relative

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  • Primary resection of the obstructing lesion or clearance of the obstructing calculi.
  • Nondilated bile duct.
  • Proximal duodenal inflammation.
  • Potential duodenal obstruction.
  • Sclerosing cholangitis.

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Open Common Bile Duct Exploration

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Expected Benefits

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  • Removal of the stone (or stones) from the common bile duct.
  • Prevention of cholangitis and cholestatic liver injury.

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Potential Risks

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  • Bleeding requiring transfusion or reoperation.
  • Retained bile duct stones requiring prolonged T-tube drainage, additional procedures by interventional radiology, or possible additional surgical intervention.
  • Bile leak requiring prolonged T-tube drainage.
  • Iatrogenic injury to the biliary tree or duodenum.
  • Surgical site infection requiring drainage or antibiotics.

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Transduodenal Sphincteroplasty

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Expected Benefits

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  • Removal of the stone (or stones) from the distal common bile duct.
  • Prevention of cholangitis and cholestatic liver injury.

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Potential Risks

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  • Bleeding requiring transfusion or reoperation.
  • Bile leak requiring prolonged drainage, drain placement, or reoperation.
  • Duodenal leak.
  • Iatrogenic injury to the bile duct or duodenum.
  • Pancreatitis.
  • Biliary stricture.
  • Surgical site infection requiring incision and drainage or antibiotics.

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Choledochoduodenostomy

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Expected Benefits

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  • Restoration of enteric biliary drainage.
  • Prevention of cholangitis and cholestatic liver disease.

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Potential Risks

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  • Bleeding requiring transfusion or reoperation.
  • Bile leak requiring prolonged drainage, drain placement, or reoperation.
  • Surgical site infection requiring drainage or antibiotics.
  • Conversion to choledochojejunostomy if choledochoduodenostomy cannot be performed.

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