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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.

  • For all procedures, the patient should be supine.

Open Common Bile Duct Exploration

  • 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.

Transduodenal Sphincteroplasty

  • 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.

Choledochoduodenostomy

  • 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.

Open Common Bile Duct Exploration

  • 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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