Chapter 12. Management of Complex Biliary Stone Disease

Open Common Bile Duct Exploration

• 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.

Transduodenal Sphincteroplasty

• 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.

Choledochoduodenostomy

• 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.

Open Common Bile Duct Exploration

Absolute

• None.

Relative

• Previous biliary bypass.

Transduodenal Sphincteroplasty

Absolute

• None.

Relative

• 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.

Choledochoduodenostomy

Absolute

• Duodenal obstruction.

Relative

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

Open Common Bile Duct Exploration

Expected Benefits

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

Potential Risks

• 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.

Transduodenal Sphincteroplasty

Expected Benefits

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

Potential Risks

• 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.

Choledochoduodenostomy

Expected Benefits

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

Potential Risks

• Bleeding requiring transfusion or reoperation.
• Bile leak requiring prolonged drainage, drain placement, or reoperation.
• Surgical ...