Gallbladder stone combined with common bile duct stone is a common disease in hepatobiliary surgery, and the classic procedure for its treatment is open cholecystectomy and T-tube drainage, which has been used in primary hospitals. This method has been used in primary care hospitals. The long hospitalization time of patients and longer placement of “T” often lead to loss of digestive fluid, local infection, pain and other discomforts. The advent of choledochoscopy has brought a boon to the treatment. One-stage suturing of the common bile duct under the guidance of choledochoscopy can avoid the inconvenience of carrying a “T” tube and improve the quality of life of patients. We selectively performed one-stage suturing in 50 patients according to the specific intraoperative conditions, and we report the following.
I. Clinical data
From December 2003 to May 2013, 185 cases of choledochotomy were performed in Pucheng County Hospital in Shaanxi Province, and 135 cases were placed with a “T” tube after surgery. During the operation, 50 patients, 32 males and 18 females, aged 32-65 years, with a mean age of (43.7±19.5) years and a disease duration of 1-10 years, were selectively sutured in one stage according to their specific conditions. Case selection criteria.
(1) No recent history of significant epigastric pain or acute attacks;
(2) Preoperative gallbladder stones combined with common bile duct stones were confirmed by upper abdominal ultrasound and MRCP examination;
(3) Preoperative dilated common bile duct (internal diameter ≥1.0 cm);
(4) Preoperative jaundice with total bilirubin of 100 µmol/L and direct bilirubin of 65 µmol/L;
(5) All patients had no history of upper abdominal biliary tract surgery;
(6) Patients with combined hypertension with grade I hypertension and ideal blood pressure control, and diabetic patients with stable blood glucose of <7.0 mmol/L for more than six months;
(7) No history of hypoproteinemia and long-term use of hormones for treatment.
II. Surgical method
General anesthesia with tracheal intubation was adopted in the supine position, and the incision was chosen to be 10-15 cm in length in the median incision next to the rectus abdominis muscle. Intraoperative choledochoscopy routinely explored the left and right hepatic ducts and the lower part of the common bile duct, and the standard was that the choledochoscope passed smoothly through the sphincter of Oddi into the duodenum, and no residual stones occurred under direct vision.
Blind stone extraction and repeated probing of the biliary probe causing edema and bleeding of the bile duct as well as mechanical damage to the bile duct leading to the occurrence of false tracts are contraindicated during the operation. The F10-F12 catheter was repeatedly flushed out the small sediment-like stones in the bile duct to ensure that no stones remained in the bile duct.
After choledochoscopic exploration with smooth access to the duodenum free of residual stones 5-0 absorbable non-invasive sutures were used to close the common bile duct incision with full external horizontal mattress sutures and final sutures to the hepatoduodenal ligament plasma membrane [1]. No significant bile leakage or bleeding occurred in the abdominal cavity after the suturing was checked. A porous latex drainage tube was routinely placed at the foramen ovale and the incision was closed in layers.
III. Postoperative management
All patients stopped gastrointestinal decompression on the second postoperative day and received 50% magnesium sulfate solution orally, 20 ml/d, 3 times/d to promote the relaxation of the sphincter of Oddi, reduce biliary pressure, reduce the chance of bile leakage, closely observe the amount and nature of drainage in the drainage tube, and use small doses of intravenous dexamethasone 5~10 mg/d for no more than 3 days to fully reduce biliary edema and prevent recurrent Biliary tract exploration-induced acute biliary ductitis and acute pancreatitis.
Discussion
The incidence of gallbladder stones secondary to, and combined with, common bile duct stones has been reported in the foreign literature as 10%-15% [2] and in China as 5%-29%, with an average of 18% [3]. In the era without choledochoscopy, cholecystectomy, choledochotomy for stone extraction, and “T” duct drainage, the bile ducts were blindly explored with biliary probes and lithotripters only by the clinical experience of the surgeon, and there was a lack of understanding of the lesions in the bile ducts, especially the function of the distal biliary sphincter of Oddi, and the condition of the intrahepatic bile ducts. The incidence of postoperative biliary infection, biliary pancreatitis, biliary bleeding, stone remnants, bile leak, incisional infection, distant biliary stricture, stone recurrence and other complications are high.
At the same time, the routine placement of “T” tube can easily cause water-electrolyte disorder, digestive dysfunction, retrograde biliary tract infection, “T” tube dislocation and other inconveniences, which increase patients’ pain, prolong their hospital stay and seriously affect their quality of life [4 The quality of life of patients is seriously affected [4], and the hospitalization cost is increased. Furthermore, clinical studies have shown that the complication rate associated with “T” duct drainage is 15.3% [5].
With the advent and improvement of fiberoptic choledochoscopic devices, the update of suture materials and the continuous improvement of suturing techniques have made the one-stage bile duct suturing more safe and reliable. Intraoperative choledochoscopy allows the operator to directly visualize the lesions in the bile duct, which significantly reduces the incidence of residual bile duct stones, reduces bile duct edema and the damage caused by blind exploration of the bile duct, and provides a broader prospect for the treatment of bile duct stones with a higher success rate of endoscopic bile duct extraction [6].
The treatment experience of our case group of 50 patients showed that one-stage suturing of the common bile duct exploration facilitates the entry of bile into the intestine, which is conducive to maintaining water-electrolyte balance as well as promoting nutrient absorption in the intestine; avoiding complications associated with the placement of T-tubes, shortening the course of treatment, and reducing patients’ pain and economic burden [7]. The key to one-stage bile duct suturing is to select a suitable case, and a comprehensive assessment of the patient’s general condition is needed before surgery.
According to the experience of our patients, the selection of patients for one-stage suturing should have both the following conditions.
① Negative bile duct exploration.
②The stones in the bile duct have been completely removed by choledochoscopy.
③The internal diameter of the common bile duct is ≥1.0 cm.
④The lower end of the bile duct was patent and the sphincter of Oddi was functioning well. No serious inflammation, edema, scar, or stricture existed in the bile duct.
⑤ No tension or little tension after bile duct suturing.
(6) No repeated probing or mechanical injury to the bile duct during surgery.
(7) No diverticula and pseudo-tracts occur during intraoperative choledochoscopic exploration.
The following principles should be strictly followed intraoperatively.
① Before the first-stage suture of the common bile duct, the right and left hepatic ducts, each branch bile duct, and the lower part of the common bile duct should be thoroughly examined by choledochoscopy, and the stones should be cleared by direct visualization, and no biliary bleeding or biliary injury should occur.
② Avoid excessive stripping of the common bile duct wall to damage the blood flow of the bile duct wall to avoid affecting the postoperative healing of the duct wall.
③Suturing was performed with 5-0 absorbable non-invasive sutures, and the common bile duct incision was closed with a full-layer external horizontal mattress suture to reduce the occurrence of postoperative biliary stricture and recurrent stone production.
④The suture adhered to the principle of tension-free, uniform, and moderate, plus the encapsulation of the hepatoduodenal ligament plasma membrane.
⑤ Oral administration of 50% magnesium sulfate solution for catheterization the next day after surgery to reduce biliary pressure and promote relaxation of the sphincter of Oddi.
⑥The porous latex drainage tube was routinely placed in the foramen ovale, and the time of removal was decided according to the amount and nature of drainage fluid.
In summary, one-stage suturing of the common bile duct is more effective than traditional choledochotomy and “T” drainage in reducing the discomfort caused by the placement of T-tubes, greatly shortening the patient’s recovery time, improving the patient’s postoperative quality of life, and reducing the patient’s hospitalization costs. As long as the indications and contraindications of choledochotomy surgery are reasonably mastered, the skills and techniques of bile duct suturing are skillfully mastered, and postoperative observation and care are meticulously performed. One-stage suturing of the common bile duct exploration plays a greater clinical application value in the treatment of common bile duct stone and is worthy of clinical promotion and application.