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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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  • For all procedures, the patient should be supine.

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Open Common Bile Duct Exploration

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  • A T-tube cholangiogram is performed on postoperative day 3. If there is no residual obstruction, it can be clamped to allow for internal biliary drainage.
  • The T-tube can be removed in the office 3–4 weeks postoperatively.
  • If there are retained calculi, the T-tube tract can be used for stone extraction by interventional radiology.

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Transduodenal Sphincteroplasty

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  • Nasogastric decompression via low continuous wall suction should be continued for 3–5 days to allow for resolution of transient duodenal obstruction from duodenal edema.
  • After the nasogastric tube is removed, with the return of bowel function, clear liquids can be started and the diet advanced as tolerated.
  • If no bilious output occurs after resumption of diet, the drain can be removed.

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Choledochoduodenostomy

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  • If no bilious output is noted, the drain can be removed a few days after the procedure.
  • A nasogastric tube attached to low continuous wall suction should be continued for 3–4 days postoperatively. With the resolution of ileus, it can be discontinued and the diet advanced as tolerated.

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Open Common Bile Duct Exploration

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  • Iatrogenic injury to the common bile duct or duodenum.
  • Retained stone despite exploration.
  • Bile leak from the T-tube.
  • Cholangitis.
  • Excessive bile loss requiring fluid replacement.
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