Indian Journal of Surgery Medknow Publications on behalf of Association of Surgeons of India ISSN: 0972-2068 Vol. 65, Num. 1, 2003, pp. 86-88

Indian Journal of Surgery, Vol. 65, No. 1, Jan.-Feb. 2003, pp. 86-88

Choledocho-Duodenostomy: A Safe, Simple and Useful Procedure for Rural Surgical Practice

Sitanath De

Banaphool Clinic, Jhargram, Midnapore District. 721507, WestBengal
Address for correspondence: Dr. Sitanath De, Banaphool Clinic, Jhargram, Midnapore District-721507, WestBengal

Paper received: July 2002
Paper accepted: November 2002

Code Number: is03017

Abstract

A series of 70 consecutive cases of Choledocho-Duodenostomy (C-D) performed after exploration and removal of stones from common Bile duct (CBD.) in benign Calculous disease of CBD. Follow-up over 29 years showed operative procedure to be simple, safe effective, the most economical and accessible to the rural patient.

Key words: Choledochoduodenostomy, Common bile duct

INTRODUCTION

The author has been practicing surgery in a small town in rural West Bengal for the last 32 years. Although conditions have improved slightly in recent years, the facilities available remain minimal. Anaesthesia is still administered by trained general practitioners, with the occasional help of a qualified anaesthetist when available. No other qualified staff is obtainable, forcing the author to rely on surgical assistants and nursing staff, recruited from the local unemployed youth and trained by himself.

The local population is approximately 7.5 lacs. of which 45% is made up of scheduled castes and tribes, mostly agricultural workers. Gross per capita income is Rs. 345 per month (1991 Census) rising recently to Rs.1,200, to maintain a family of minimum 4 members. Most patients have to travel 40-200 kms to access any form of surgical care. As a result, the patients resort to unscientific remedies (quackery). This leads to a considerable delay in proper treatment, by which time the patient has commonly developed malnutrition and anaemia.

Against this background, the author has concentrated on developing specific surgical procedures adapted to meet the needs of the community. The aim is to find the procedures giving the best curative results, which are also the most cost-effective for the patient and which can be most easily managed with the limited skills available. This paper presents an outline and evaluation of one such procedure.

Incidence of exploration of C.B.D. in gall bladder disease with stone is approximately 20%. The chance of missing "small stones" after exploration of C.B.D. is approximately 9-11%. "Stasis factor" in distal C.B.D. is responsible for the recurrence of stones in C.B.D. Therefore, in a rural surgical Clinic, where presentation of G. B. disease is common, it is essential for the surgeon to have a plan for dealing with C.B.D. stones.

The alternative methods of treatment are :

i) Transduodenal sphincterotomy with temporary "T"-tube drainage of C.B.D.
ii) Forceful dilatation of the sphincter.
iii) Choledocho-enterostomy (Roux-en-Y)
iv) Choledocho-duodenostomy (C-D)

For last 29 years (Jan. 1971- April 2001) C-D has been adopted in our rural Clinic as a primary definitive procedure, dealing with the "Stasis Factor" as well as small " Missed stones" after removal of stone or stones from C.B.D.

The objective of this study was

i) To evaluate the safety of this procedure.
ii) To evolve a procedure which can be well managed with minimum facilities.
iii) To eliminate physical and financial hardship by referring the patient to the nearest urban surgical centre, approximately 150 Km away.
iv) To develop a low-cost procedure within the means of the patient.
v) To put on record, the long-term experience of the management of C.B.D. stone in a small rural surgical clinic.

MATERIAL AND METHODS

Between January 1971-April 2001, 354 cholecystectomies were performed. Of these, exploration of C.B.D. was done in 70 cases except for three where the C.B.D. was full of sludge and mucus, of these 70 cases there was:

• Jaundice prior to surgery in 41 cases
• Jaundice at the time of surgery in 19 cases
• No history of Jaundice in 10 cases.

Indication for exploration of C.B.D.

i) History of cholangitis with or without jaundice
ii) Oral cholecystogram showing multiple small stones
iii) Operative findings:

a) Palpable stone in C.B.D.
b) C.B.D. dilated more than 1 cm.
c) Aspiration of dirty bile from C.B.D.
d) Thick indurated C.B.D.

iv) U.S.G. shows a C.BD. of greater than a centimeter width.

Operatrive Technique

All cases are operated under Open Ether anaesthesia. Diathermy is not used.

A longitudinal incision is made in the anterior lowest segment of the supraduodenal portion of C.B.D with the help of two stay sutures to steady the duct.

Stones are removed and C.B.D. is flushed out using normal saline.

A test probe (3mm) is passed through sphincter of oddi to check free passage of C.B.D:

i) Not passable-28 cases
ii) Sphincter of oddi patulous, admitting 16/20 F.G. Male

Metallic urethral dilator easily-3 cases

i) Stone impacted at ampulla-2 cases
a) Transuodenal sphincterotomy performed to remove stone.

Finished with Complementary C-D

Choledocho-Duodenostomy (Method of Floreken)

A transverse incision is made on the upper anterior surface of Duodenum along its longitudinal Muscle coat, centering the lower end of the incision on C.B.D. The length of the incision should be sufficient to allow a stoma of 2.5 cm. The one-layer anastomosis is made, using atraumatic chromic catgut (00) starting from the lower end of the incision on the duct. Two interrupted sutures before the start of the continuous stitch help to preven inversion of the edges of C.B.D. and duodenal incision where the continuous stitching ends. All the knots are kept outside. The wound is closed in layers with a sub-hepatic drain.

Postoperative Management

The total amount of sub-hepatic drainage varies between 400-600 mls over a 2-3 day period. The bile is faintly colored during the first 24 hours. This is followed by clear sanguinous fluid, reduced in amount. The drain is removed when the patient starts passing flatus, usually on the 3rd day. The patient is ambulatory from the 3rd post-operative day, greatly simplifying nursing management. The stitches are removed on the 9th postoperative day and the patient discharged on the 10th post-operative day.

RESULTS

L Operatie Mortality-Nil

Suture leak-Nil

Sub-acute intestinal obstruction from Ascariasis-1. This patient developed incisional hernia which has since been successfully repaired.

Wound Infection-3

Post-Transfusion Malaria-2

Post-Transfusion Hepatitis-2

Long-Term Follow-up

Lost of follow-up 12 cases

Death within 10 years from causes not related to operation-14

Overall view in the remaining 44 cases :-

No clinical evidence to suggest recurrence of stone, or "Missed stones" in C.B.D.

i) Expensive investigations such as repeated ulltrasonography, cholangiagram or liver function tests were avoided.
ii) Mild dyspeptic symptoms found in 16 patients due to helminthiasis and ascariasis, which have been successfully treated.
iii) A few patients with persistent dyspeptic symptoms showed evidence of aerobilia in liver at ultrasonography. Whether this is a cause of dyspeptic symptoms remains to be studied.

Cost Analysis (Current price):-

L Medicine expenses Rs.2700

Cost of bed (including nursing charge)

Rs. 70 per day x 10 days Rs. 700

Operation charges varying from Rs.3000 to Rs. 5000

Total cost for patient between Rs. 6,400 to Rs.8,400

Cost does not include food which is provided by the patient's relatives.

Cooking facilities are available and a suitable diet is advised by the paramedical staff.

DISCUSSION

The safety of C-D is indicated by the fact that operative mortality is nil and morbidity is negligible. The fact that there is no recurrence of C.B.D. stone indicates the curative effectiveness of the procedure, particularly as it facilitates the passage of small "Missed Stones" into the duodenum through the large stoma.

The following points illustrate the simplicity and economic advantages of this procedure:

i) No preoperative cholangiogram is done as it is thought to be unnecessary
ii) No expensive suture material is used as Chromic catgut (00) is found to give a equally satisfactory result.
iii) There is no Kocher's mobilization of duodenum or mobilization of C.B.D. from its peritoneal sheath. It is felt that respect to local tissue and its blood supply produce good anastomatic union.
iv) The discomfort of a "T"-tube and the difficulties of its management are avoided. The need for cholangiogram before removal of "T" tube is also avoided. The early mobility of the patient as a result of this procedure, is also extremely beneficial, particularly to the middle-aged patient.

After cholecystectomy, only one atraumatic chromic catgut is the extra expense for such a curative procedure.

Finally, in comparison with alternative optional procedures for benign C.B.D. diseases, C-D has been shown to produce minimal side-effects. Both Transduodenal sphincterotomy and forceful dilation have the disadvantage of inducing pancreatitis, sometimes with fatal outcome. Whereas Choledocho-enterostomy is a lengthy procedure which involves and additional intestinal anastomosis. As bile drains into the duodenum in C-D, it appears to be a more physiological treatment.

CONCLUSION

A series of 70 cases of C-D has been performed safety and effectively in a small rural clinic, relying only on the most basic infrastructure and "assistants" trained personally by the author. The true aim of the rural surgeon in brining effective and affordable treatment to the patient, "to the door-step" has been met in these cases, at least. It is therefore tempting to propose that Choledocho-duodenostomy should be a primary definitive procedure, after an exploratory operation of C.B.D. in all cases where it is possible to make a stoma of adequate size. Such an operation could be a valuable tool in the hands of every rural surgeon.

Acknowledgements

I would like to thank my local collegues, Dr. Mukulika Dey M.B.B.S., D.G.O.D.A. and Dr. Sibaram Das M.B.B.S. and my large family of paramedical staff for their continued assistance and support.

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