OPERATIVE LIVER
r
OPSY IN FUNCTIONAL BILIARY DISEASE
following morphine were all abnormal (Ham et alii. 1978) . The pathologicul changes we have demonstrated are compatible with cholestasis and peribiliary inflammation , possibly due to intermittent elevations of biliary pressure . Such pressure elevation may be related to dysfunction of the distal bile duct sphincter, either as a primary disorder, or as a sequel to the passage of small gallstones or " microcalculi ". We cannot discount the latter Possibility in our patients , although it would be difficult to explain the persistence of the patient's symptoms and the liver biopsy abnormalities on this basis . Whatever the cause of the hepatic abnormalities, they do provide an objective basis for assessing the value of the various preoperative diagnostic methods described previously (Ham et alii , 1978)
HAM ET ALII
ACKNOWLEDGEMENTS We thank Dr J. V. L. Colman , Dr G. R. Pritchard afld Dr B. W. Yeo for permission to include patients under their care in this report. We are grateiu l to Dr M. McGlynn , Dr A. Greenberg and Dr E. C. P. Shi for conducting the morphine provocation tests . Miss E. Gray gave expert assistance with the manuscript. REFERENCES ACOSTA, J . M. and LEDESMA, C . L. (1974), New Engl. J . Med., 290: 484 . Et.UND , Y. A . and ZETTERGREN , L. S. L . (1957) , Acta chir. scand., 113: 201 . HAM , J . M., BoLIN , T . D., WiLTON , N ., STEVENSON, D. and JEFFERIES, i . (1978) , AUST. N.Z .J . SURG., (1977), Arch. Surg., 112: 959 .. MI CHEL, S. L., LIPSKY, R. and MORGENSTERN, L. (1977) , Arch. Surg., 112: 959. PoULSON, H . and CHRISTOFFERSEN , P. (1970) , Acta mrcrobiol. scand.. Section A., 78: 571 . RAVEN , R. L. (1975). Ann. roy. Col/. Surg. Engl., 56: 89. SCHEUER, P. (1973) . Liver Biopsy Interpretation. 2nd Edition, Balllere Tindall . London.
UNRESECTABLE MALIGNANT OBSTRUCTION OF THE BILE DUCTS JOHN WONG, S. T . K. LIM. K. H. LAM AND G. B. ONG
Department of Surgery, University of Hong Kong Queen Mary Hospital, Hong Kong Over a 13-year period we encountered 135 patients with malignant obstruction of the bile ducts, and in 81 of these patients only palliative surgery was possible. The type of operation was largely determined by the site and nature of the obstruction and the condition of the patient. The operative mortality of palliative operation was 37%. Relief of jaundice or pruritus was obtained in 68%, and this figure included a number of patients who died In th e first 30 days. The majority of survivors lived lor between three and four months alter operation, although occasional patients have lived lor more than one year.
MALIGNANT obstruction of the biliary tract is a highly lethal condit1on . The causes include carcinoma of the bile ducts, gallbladder, pancreas and periampullary region, and metastatic lymph nodes in the porta hepatis. In this group of conditions . only carcinoma of the periampullary region has a fairly good prognosis, and cure by radical resection is a possibility . All other causes of malignant obstruction of the bile ducts. regardless Of the form of treatment . carry five-year surv1val rates of not more than 10%. Thus for malignancies of the proximal bile ducts. gall bladder, and pancreas, and malignant Aepnnts Dr John Wong Department of Surgery, Un1vers1ty of Hon g Kong . Oueen Mary Hosp1tal Hong Kong
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obstruction by lymph nodes in the porta hepatis, treatment is directed primarily at palliation to relieve jaundice and pruritus . Even when resection with the object of cure is performed in these conditions, the low survival rates underline the palliative nature of these radical operations . We report herein our 13-year experience of 81 patients in whom palliative operations were performed for obstructive jaundice caused byunresectable malignant disease. PATIENTS In the 13 years from 1965 to 19i7, 135 pat1ents. with malignant obstruction of the bile ducts were admitted to the University Surgical unit, Queen Mary Hospital . Hong Kong . Of these patients 81 503
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TABLE 1
Cause of Obstruction and Natura of Operation Procedures Performed Conditions
Total No.
Curative
Palliative
Laparotomy Atone
Ca bile ducts
72
27
42
3
Ca pancreas
43
13
30
9
8
0
0 1'
Ca penampullary region Ca gallbladder
5
Secondaries· in
4
0
4
0
135
49
81
5
porta hepatis Total
·Patient discharged himself from hospital against medical advice.
were deemed incurable by resection, and palliative operations were carried out. There were 56 men and 25 women . Their ages ranged from 35 to 93 years, with a mean of 62.4 years . The sites and causes of the obstruction, the distribution of patients, and the nature of operations carried out are shown in Table 1. Palliative Operations for Malignant Obstruction of Bile Ducts The aim of these operations is to decompress the bile duct so that jaundice and pruritus may be relieved . This may be achieved by internal or external drainage or by a combination of both methods. For internal drainage, the site of the biliary tree available for decompression is dictated by the location of the obstruction, and may thus be gallbladder, common bile duct, common hepatic duct, left or right hepatic duct, or intrahepatic duct. The part of the gastrointestinal tract used for anastomosis to the proximal obstructed biliary system is usually a loop of jejunum, but sometimes the stomach or duodenum . Occasionally the gall bladder may act as an intervening organ between the right hepatic duct or its anteroinferior segmental branch and the jejunum. External drainage is by intubation, and this may be accomplished by a transhepatic tube (using a straight T or U tube), by a T tube placed in the common hepatic or common bile duct, or by a cholecystostomy. Often a combination of both methods is employed using a tube either as a temporary stent while an anastomosis heals over, or using a tube which traverses the site of malignant obstruction with side holes made in the proximal and distal parts of the tube to allow drainage of bile internally.
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CHD + CBD = UPPER & LOWER CBD = CHD + L. HD = CHD + L. & R. HD = TOTAL : 72
5 1 2 3
FIGURE 1· D1stnbut1on of 72 pnmary carc1nomas of the bile ducts. C ; Common , B ; B1te, H ; Hepatic, D ; Duct . L ; Left , R ; Right.
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WONG ET ALII TABLE 2
Cause of Obstruction. Operations Performed, and Survivors
Ca Bile Duct
Ca Gallbladder
Ca Pancreas
Secondanes in
Porta Hepatls Procedures
No. of Patients
Cholecystjejunostomy
No. Of Patients
Survivors
2
Survivors
10~
5
No . of Patients
Survivors
No . of Patients
Survivors
Cholecystantrostomy CholedochJejunostomy
7( 1)'
4
Choledochoduodenostomy
6
5
Choledochoantrostomy
3(1)
2
5( 1)
3
Hepaticojejunostomy
3
2
longmire operation
5
3
0 0
Cholangiojejunostomy Rt cholarlgiocholec ysto stomy
1t
Rt cholangiocholecystostomy With cholecystjejunostomy
1
10(1)
6
tOt
6
Cholecystostomy
2
Intubation. transhepati c T Tube : Through tumour above tumour
2 0
2 1
1 0
17
5
3
3
Total
43
30
28
3
One patient had both proce dures. One pat1ent had tripl e anastomoses. Number 10 brackets shows leakage of biliary-entenc anastomosis . Anastomotic leakage contributory to death .
··survivors'" refers to patients who lived beyond 30 days.
periphery of the liver, the duct having been isolated after amputation of the left or right liver edge. Table 3 shows the different causes of obstruction, the mean period of survival of patients who lived beyond 30 days after the operation , and the incidence of relief of symptoms . A number of patients were relieved of jaundice and pruritus after operation, although they did not survive beyond 30 days.
RESULTS
The distribution of 72 primary carcinomas of the bi le ducts is shown in Figure 1. The types of palliative procedures performed for each condition, the number of patients operated on, and the number of survivors, are shown in Table 2. Hepaticojejunostomy refers to anastomosis of a jejunal loop to the hepatic ducts in the porta hepatis. Cho langiojejunostomy or cho langiocho lecystostomyy refers to anastomosis of the jejunum or gall bladder to an intrahepatic duct not located in the edge of the liver. Longmire operation refers to jejunum anastomosis to an intrahepatic duct at the
For the who le group of patients, the operative mortality (within 30 days of operation) was 30 out of 81 (37%) . The causes of death were usually multiple and consisted of malignant cachexia, hepatic and
TABLE 3 Cause of ObstructiOn and Resulls of Operation
Mean Period No. of Pat1ents
Survivors
(months)
Relief of Symptoms
Ca bile ducts
42
28 (67%)
3.9
28 (67%)
Ca pancreas
30
17 (57%)
3.1
21 (70%)
5
3 (60%)
4.0
3 (60%)
3 (7 5%)
53
3 (75%)
51 (63%)
37
55 (68%)
Conditions
Ca gallbladder
of Survival
Secondanes tn
porta hepa11s 81
Total
'"Surv1vors'" refers to pa t1 ents who lived beyond 30 days
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renal failure, gastrointestinal bleeding, and pneumonia. Leakage from biliary-enteric anastomosis was not a serious problem in our series of patients. There were four patients with anastomotic leakage, and in one patient this complication was contributory to death (Table 2). In the other three patients, bile leakage stopped within two weeks without further operation . The mean survival period of the survivors was 3.7 months, one patient living for 18 months before succumbing from metastasis. Relief of symptoms was obtained in 55 out of 81 (68%) patients after operation. Of the remaining 26 patients, 10 (12%) were not relieved of their obstruction, and 16 (20%) died in the early postoperative period, so that the result could not be assessed. Three patients who underwent internal drainage procedures not commonly described are presented . CLINICAL RECORDS CASE 1.- This patient was a 25-year-old Chinese labourer who presented with one month 's history of repeated attacks of dull upper abdommal pain and jaundice. A hard lymph node one centimetre in diameter was found 1n the lett supraclavicular fossa The liver was not enlarged . Investigation showed biochemical evidence of biliary obstruction . A preoperative percutaneous cholangiogram revealed dilated mtrahepatic ducts, but the extrahepatic ducts were not visualized . At operation, a large cancerous mass was found in the porta hepatos woth direct infiltratoon mto the liver substance. Exploration in the region of the porta was therefore not attempted. Dissect ton was commenced in the right free margon of the liver and dtrectly into the liver substance. A small duct of the right lobe was isolated . and after some difficulty a portion of the duct one centimetre in length was freed . A small tube was inserted into the duct and fixed by a suture . A Roux-en-Y loop of upper jejunum was anastomosed to the capsule of the liver, with the duct lying free in the jetunum. The tube stent was brought out through the jejunal loop and then through the anterior abdominal wall.
After operation the patient did well and his liver function rapidly inproved. A retrograde cholangiogram performed two weeks after operation showed decompression of the intrahepatic duct, drainage of contrast medium into the jejunal loop, and no evidence of leakage (Figure 2) . Chemotherapy was commenced three weeks after operation, and he remained well and asymptomatic for four months before dying of metastic disease. CASE 2. - This 63-year-old Chinese housewife was admitted to a hospital in Smgapore with a four-month history of a mass in the right upper abdominal quadrant, jaundice, and pruritus. Investigations showed progressive obstructive jaundice, and an operation was performed in August 1976. At operation the liver was found to be enlarged, but the commo n bile duct and gallbladder were not distended. Exploration of the common bile duct showed obstruction of the upper part of the common hepatic duct. The stricture was dilated and biopsy carried out. A T tube was Inserted with the upper limb traversing the stricture. It was considered that she was suffering from carcinoma of the common hepatic duct, although the b1opsy specomen taken at the operation did not show malignancy. Initially she was relieved of her jaundice and pruritus, but a month later her symptoms returned and she was transferred to Hong Kong for further management. On admission. she was moderately jaundiced and a four centimetre non- tender hepatomegaly was palpable. Reoperation was performed in November 1976. There was ascites, and the lover was enlarged and congested . A deepsea ted large tumour mass was felt at the dome of the right lobe. Exploration of the common bile duct through the previous choledochotomy site confirmed the presence of obstruction of the upper common hepatic duct dnd the left and right intrahepatic ducts. The gall bladder was mobilized from its bed. and the anteroonferior segmental duct was found by dissecting into the liver substance of the gallbladder fossa . A two centimetre segment of this duct was exposed , and a side-to-side intrahepatic cho langiocholecystostomy was performed using one layer of onterrupted fine catgut over a small Portex catheter. The catheter was then brought to the exteroor through a cholecystotomy . A cholecyst1ejunostomy was not deemed necessary, as the sote of obstruction wa& intrahepatic. The left duct was dilated and a transhepatic tube placed woth one end in the common bile duct and the other end traversong the tumour and brought out through the surface of the left lobe of liver and then to the exterior. A number of holes were cut 1n this tube 1n the ontrahepatic portion, so that internal drainage could take place when the tube was clamped . Her condition did not warrant a second internal drainage procedure on the left lobe. After operation, there was progressive alleviation of her symptoms and improvement on the results of liver function tests . A retrograde cholangiogram through the cholangiocholecystostomy tube showed decompression of the nght hepatic duct system (Figure 3) , and the tube was removed . A cholangiogram through the transhepatic tube showed a decompressed left duct system and flow of contrast medium into the duodenum . The left transhepattc tube was left 1n s1tu. She rema ined well and gained 15 kg on weight over the next 6 months. However, it was decided to reoperate on thos patoent for two reasons: first , to establish a pathological diagnosos; and second , to determine of an internal drainage operatoon was necessary for the left lobe.
FI GU RE 2: Case 1; retrograde cholangiogram through cholangtOJelunstomy tube, showong decompresljoon of the ontrahepatic biliary system and flow of contrast medium onto the 1e1unum
506
At operat1on the liver was found to have become smaller and less congested . The mass felt on the dome of the right lobe was unchanged. The prevoous cholangoocholecystostomy was palpated through the wall of the gallbladder and was found to be patent. Transhepatic biopsies and boopsoes of tossue at the porta were carried out , and frozen section exam1natoon revealed mucin-secreting adenocarcinoma. The common bile duct was opened and the left transhepatic tube removed . Probing of the left hepatic duct showed 11 to be widely patent It was then dec1ded not to perform Internal dra1nage. A T tube was mserted in the common bile duct with the upper lomb
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FIGURE 3: Case 2: retrograd e cholangi ogram th rough the cholangiochole cystostomy tube showing patency of the anastomosis and visualization of the right intrahepatic biliary system. The site of the hepatic duct obstruction is some distance from the cysti c duct junction to the common bile duct.
traversing the site of the previous stricture of the left hepatic duct. After operation her convalescence was uneventful. A retrograde cholangiogram after ten days showed the lett duct system to be normal in calibre, and contrast medium flowed freely into the duodenum . The T tube was removed on the 14th day. Six months after this operation and twelve months after her f1rst operation in Hong Kong, she remamed well and asymptomatic. CASE 3.- This 75-year-old Chinese housewife was admitted to hospital in June 1977 in shock from upper gastrointestinal bleedmg . She had been a diabetic for two years and was being treated with oral hypog lycaemia drugs. Immediate gastroduodenoscopy showed active bleeding from a chro nic duodenal ulcer. Emergency operation was carried out , and a :we-centi metre posterior wall c hronic ulce r was found in the lrst part of th e duodenum w1th act1ve bl eed ing from the gastroduodenal artery. In addition, empyema of th e gallbladder, was present, with two stones in the gallbladder one of Which was 1mpacted in Hartmann's pouch. The bleeding site was Plicated and truncal vago tomy and Heineke-Mikulicz Pyloroplasty were performed. Cholecystostomy was carried out after removal of the two stones. Three weeks after operation she became jaundiced and began vomiting after meals. A retrograde cholangiOgram via I he cholecystostomy tube showed obstruction of the common bile du ct with proximal duct dilatat ion and no contrast medium entenng . the duodenum (Figure 4). Banum meal X-ray exammat1on revea led obstruction at the dis tal portion of the first part of the duodenum. Carcinoma of the pancreas was suspected and reoperation was performed . At operation a mass was found 1n the head o f the pancreas , and frozen sectio n examination of a biopsy specimen showed adenocarcinoma . Cholecystectomy was performed, and the dilated common hepatic duct was divided and the lower end closed . Th e first part of the duodenum was then divided and the
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FIGURE 4: Case 3; retrograde c holangiogram through cholecystostomy tube showing dilated com mon hepatic and intrahepatic ducts. There is obstruction to flow of contrast medium beyond th e junction of the cystic duct and the common bile duct. distal end closed. The proximal common hepatic duct was then anastomosed end-to-end to the duodenum by one layer of interrupted catgut sutures over a latex )ube , one end of which was brought out through the anterior wall of the stomach and then through the abdominal wall . An antecolic gastrojejunostomy was constructed . She made a good recovery after this operation, and a cholangiogram via the transgastric tube showed patency of the anastomosis with decompression of the biliary tree (Figure 5) . Results of her liver function tests returned to normal, and she was able to eat a standard ward diet without discomfort. She rema1ned well and asymptomatic for five months after her second operation before dying of metastatic disease. DISCUSSION
For malignant obstruct!on of the bile duct, the only hope for cure is by resection . Although this form of surgery is possible in more than half of patients with periampullary carcinomas (Douglass, 1974; Makipour et alii, 1976; Wise et alii, 1976; Nakase et alii , 1977), it is usually not applicable to malignancies of the bile duct, gallbladder and pancreas, or obstruction by malignant lymph nodes in the porta hepatis (Thorbjarrason , 1959; Braasch et alii, 1973; Fortner et alii, 1976; Nakase et alii, 1977). Radical surgery In malignant obstruction of the bile ducts should thus be reserved for the small number of selected patients who have genuine 507
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AGURE 5: Case 3; retrograde cholangiogram through transgastr1c tube show1ng patency of end-to-end choledochoduodenal anastomosis with decompression of the biliary system .
prospects of cure (Warren et alii, 1975; Wise et alii, 1976; Tompkins et alii, 1976). In the majority of patients, only palliative procedures are appropriate. Carcinoma of the bile ducts has been the cause of obstruction in over half of our patients. We have included carcinoma of the lower end of the common bile duct in this group, and this may account for the relatively large numbers as well as the high resection rate as compared with that in other series (Braasch et alii, 1967; Ross et alii, 1973). Another explanation for our high incidence of bile duct cancers may be related to the prevalence of clonorchiasis in our patients . Our operative mortality for palliative operation of bile duct carcinomas is 14 out of 39 (36%) , and is similar to that reported by Ragins et ali1 , (1973), Ross et alii, (1973) and Fortner et alii (1976) . Because of the frequency with which carcinoma of the bile duct is situated at the junction of the common hepatic duct with the left and right hepatic ducts (a finding similar to that in the series reported by Braasch et alii, (1967), palliative internal drainage has required intrahepatic ductal anastomosis to the jejunum , or anastomosis of the right hepatic duct or its anteroinferior segmental branch to the gallbladder, usually with a cholecystjejunostomy. We have, whenever possible, attempted internal drainage for high ductal carcinomas, and have been impressed with the palliative value of the right intra hepatic cholangiocholecystostomy, even when there is no apparent communication between the left and right hepatic ducts. Our experience with intubation has not' been as favourable as with biliary-enteric drainage, as
508
frequent episodes of cho langitis are the lot of many of these patients, a few of whom have required reexploration for decompression or conversion into an external fistula. However, some patients with intubation have had adequate symptomatic relief, and one patient was alive and symptom-free over one year after intubation. Similar resu lts were reported by Klatskin, (1965). Whelton et alii, (1969) and Fortner et alii, (1976) . We did not find external drainage procedures to be attended by a high mortality rate as reported by Ross et alii, (1973) . Because of certain disadvantages of intubation, such as cholangitis, loss of bile, and the necessity for a permanent tube, we have whenever possible performed internal drainage in all patients except those who have been critically ill and unable to tolerate a longer operation . It is possible in virtually all patients with malignant bile duct obstruction to perform internal drainage so long as the patient's condition permits. For carcinoma of the head of the pancreas with a dilated common bile duct, satisfactory results have been obtained with end-to-end choledochoantrostomy , or choledochoduodenostomy and gastrojejunostomy, instead of the classical triple anastomosis . In some patients with carcinoma of the head of the pancreas with a distended gallbladder, cholecystjejunostomy may not provide adequate drainage, and in two such patients , reoperation to perform internal drainage via the common bile duct was required . For carcinoma of the gallbladder with obstructive jaundice, the cause is either local recurrence after cholecystectomy or extensive local primary disease with invasion of the bile ducts. Under these circumstances. palliative decompression may be obtained by a Longmire operation , a hepaticojejunostomy, or intubation. When biliary obstruction is caused by metastatic lymph nodes in the porta hepatis, internal drainage can be performed if the liver is free of extensive tumour deposits. If there are gross hepatic metastases or widespread abdominal disease, intubation alone would be indicated. It has been our practice to operate on all patients with obstructive jaundice, even when malignancy is reasonably certain to be the cause. because concomitant choledocholithiasis is common in our community and may be an additional cause of obstruction in some patients . Furthermore. symptoms of progress1ve jaundice and pruritus are not well controlled by drugs Therefore, in spite of a high operative mortal1ty, we believe that the better palliation enjoyed by those who surv1ve warrants operative treatment in patients with malignant obstruction of the bile ducts. A UST
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REFERENCES BRAASCH, J W .. WARREN, K. W. and KUNE, G. A. (1967) , S\Jrg. Clm. N. Amer.. 47 : 627 BRAASCH , J W (1973) , Surg. Clm. N. Amer., 53 . 1217. DoUGLASS , H 0 (1974) , Surg. Annu .. 6: 161 FORTNER, J . G., KALLUM, B.O. and KtM , D. K. (1976) , Ann. Surg .. 184 68. KLATSKIN, G. (1965) . Amer. J. Med.. 38: 241 MAKIPOUR, H., COOPERMAN , A .. DAN ZI, J . T and FARMER, R. G . (1976) . Ann. Surg .. 183· 341 . NAKASE, A ., MATSUMOTO, Y , UCHIDA , K and HONJO, I. (1977), Ann Surg.. 185. 52.
WONG ET ALII
RAGtNS, H ., DtAMOND, A ., and MENG. C . H . (1973). Surg. Gynec. Obstet ., 136: 27. ROSS, A. P., BRAASCH, J W. and WARR EN, K W (1973), Surg Gynec. Obstet .. 136: 923 THORBJARNARSON, B. (1959). Cancer. ( Phtlad.) 12 708 TOMPKINS R K , JOHNSON , J ., STORM, F K and LONGMIRE , W. P (1976), Amer. J Surg., 132: 174 WARREN , K. W . CHOE, D S , PLAZA, J . and RELIHAN, M . (1975) , Ann. Surg .. 181 · 534 WHELTON , M . J ., PETRELLI, M., GEORGE, P. (1969). Quart. J . Mad., 38: 211 . WISE, l , PI ZZIMBONO, C. and DEHNER, L. P. (1976). Amer J. Surg .. 131 . 141 .
RECURRENT BILIARY CALCULI DUE TO NON-ABSORBABLE CYSTIC DUCT LIGATURES DAVID INGRAM' AND DENIS G . KERMODE'
Queen Elizabeth II Medical Centre, Perth A non-a bsorbable cystic duct ligatu re may mig rate into the c ommon b!le du ct and ~ct as a ni du s lor recurrent sto ne fo rm ati on. Fou r case hi stories are presented and the pro blem Is dtscussed. Th ts seq uel may be pre_ven ted by the use of absorbable sutures to ligate the c ystic du ct, there by redu cin g the n umb er o f patients lactng the haza rd s of recu rre nt bil iary su rger y.
RETAINED and recurrent common bi l e duct stones are an importan t prob lem of bi liary surgery . The frequency of retained stones has been reduced by the routine use of ope ra tive cholangtography (Faris et alit , 1975) . In recent years , however. there has been an increasing number of reports (Mackie et alit. 1973: Mtllbourn . 1949; Ahlberg. 1959: S1gler and Sahler, 1969: Rees and Jacob . 1977: Anderson and Blumgart . 1978) of patients in whom recurrent stones have been found subsequent to the use of non-absorbable material to ligate the cyst1c duct. This complication is preventable by the use of absorbable t ies for the cyst i c duct. Four cases presenting under the care of one surgeon (D .G . K .) are reported . CLINICAL RE CORDS CASE 1 - A 55-year-old woman was admt tt ed to hospttal tn December 1971 She had had a cholecystect omy 18 months prevtously and over the lour months pnor to thts admtSStOn had three eptsodes ol severe eptgastnc patn . one ol th ese betng assoctated woth 1aundtce and pyrexta Ftndtngs on cltntcal • Surg1ca1 Reg1strar
' Surgeon
Repnnts Mr 0 G Kermodc FA West rn Australia 6005
cs
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exammatton were normal at the ttme ol admtsston , but an tntravenous cholangtogram showed a filling defect at the lower end of the common bile duct. At operatton two silk ligatures surrounded by a friabl e mucotd stone were found and r mov d . CASE 2.- A 71-year-old man presented tn February 1972 wtlh a htstory of severe eptsodtc eptgastnc patn radtaltng between the shoulders. He had prevtously had a cholecystectomy and parttal gastrectomy tn 1943 On exammatt on he was febnle. tn patn , and Jaundtced There was marked tenderness tn the nght upper quadrant of the abdomen He had a leukocytosts of 16.400/ mm ' and results o f ltver fun c tt on tests tndtcated btltary obstructton. At operatton three large stones were removed from th e common btle duel . wht ch was three c~nttmetres tn dtameter A peroperattve postexploratory cholangtogram appeared normal. but hts postoperattve T-tub cholangtogram snowed a restdual stone . Thts was removed at a further operatton and was found to contatn a w1111e stlk ltgature ( Ftgure 1, upper) CASE 3 - A 45-year-old woman was admt\ted to hospttal tn Aprtl 1972 Wtth recurrent abdomtnal patn stnce a cholecys tectomy'" 1968. At that ttme her common btle duct was explored. but no stones were found She descnbed a classtcal btltary patn and desptte a normal tntravenous cholangtogram tt was thought that reexploratton was warranted Thts revealed a large cysttc duct stump with a stlk ltgature lytng free wtlhtn thts stump No stones were present (Figure 1. lower) . CASE 4- A 44-year-old woman was admttted to hospttal tn June 1977 w tth an attack of nght upper quadrant abdomtnal patn whtch radtated to her back. She had had a similar attack three months prevtousty , and she descnbed the patn as stmtlar
509
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OPSY IN FUNCTIONAL BILIARY DISEASE
following morphine were all abnormal (Ham et alii. 1978) . The pathologicul changes we have demonstrated are compatible with cholestasis and peribiliary inflammation , possibly due to intermittent elevations of biliary pressure . Such pressure elevation may be related to dysfunction of the distal bile duct sphincter, either as a primary disorder, or as a sequel to the passage of small gallstones or " microcalculi ". We cannot discount the latter Possibility in our patients , although it would be difficult to explain the persistence of the patient's symptoms and the liver biopsy abnormalities on this basis . Whatever the cause of the hepatic abnormalities, they do provide an objective basis for assessing the value of the various preoperative diagnostic methods described previously (Ham et alii , 1978)
HAM ET ALII
ACKNOWLEDGEMENTS We thank Dr J. V. L. Colman , Dr G. R. Pritchard afld Dr B. W. Yeo for permission to include patients under their care in this report. We are grateiu l to Dr M. McGlynn , Dr A. Greenberg and Dr E. C. P. Shi for conducting the morphine provocation tests . Miss E. Gray gave expert assistance with the manuscript. REFERENCES ACOSTA, J . M. and LEDESMA, C . L. (1974), New Engl. J . Med., 290: 484 . Et.UND , Y. A . and ZETTERGREN , L. S. L . (1957) , Acta chir. scand., 113: 201 . HAM , J . M., BoLIN , T . D., WiLTON , N ., STEVENSON, D. and JEFFERIES, i . (1978) , AUST. N.Z .J . SURG., (1977), Arch. Surg., 112: 959 .. MI CHEL, S. L., LIPSKY, R. and MORGENSTERN, L. (1977) , Arch. Surg., 112: 959. PoULSON, H . and CHRISTOFFERSEN , P. (1970) , Acta mrcrobiol. scand.. Section A., 78: 571 . RAVEN , R. L. (1975). Ann. roy. Col/. Surg. Engl., 56: 89. SCHEUER, P. (1973) . Liver Biopsy Interpretation. 2nd Edition, Balllere Tindall . London.
UNRESECTABLE MALIGNANT OBSTRUCTION OF THE BILE DUCTS JOHN WONG, S. T . K. LIM. K. H. LAM AND G. B. ONG
Department of Surgery, University of Hong Kong Queen Mary Hospital, Hong Kong Over a 13-year period we encountered 135 patients with malignant obstruction of the bile ducts, and in 81 of these patients only palliative surgery was possible. The type of operation was largely determined by the site and nature of the obstruction and the condition of the patient. The operative mortality of palliative operation was 37%. Relief of jaundice or pruritus was obtained in 68%, and this figure included a number of patients who died In th e first 30 days. The majority of survivors lived lor between three and four months alter operation, although occasional patients have lived lor more than one year.
MALIGNANT obstruction of the biliary tract is a highly lethal condit1on . The causes include carcinoma of the bile ducts, gallbladder, pancreas and periampullary region, and metastatic lymph nodes in the porta hepatis. In this group of conditions . only carcinoma of the periampullary region has a fairly good prognosis, and cure by radical resection is a possibility . All other causes of malignant obstruction of the bile ducts. regardless Of the form of treatment . carry five-year surv1val rates of not more than 10%. Thus for malignancies of the proximal bile ducts. gall bladder, and pancreas, and malignant Aepnnts Dr John Wong Department of Surgery, Un1vers1ty of Hon g Kong . Oueen Mary Hosp1tal Hong Kong
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obstruction by lymph nodes in the porta hepatis, treatment is directed primarily at palliation to relieve jaundice and pruritus . Even when resection with the object of cure is performed in these conditions, the low survival rates underline the palliative nature of these radical operations . We report herein our 13-year experience of 81 patients in whom palliative operations were performed for obstructive jaundice caused byunresectable malignant disease. PATIENTS In the 13 years from 1965 to 19i7, 135 pat1ents. with malignant obstruction of the bile ducts were admitted to the University Surgical unit, Queen Mary Hospital . Hong Kong . Of these patients 81 503
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TABLE 1
Cause of Obstruction and Natura of Operation Procedures Performed Conditions
Total No.
Curative
Palliative
Laparotomy Atone
Ca bile ducts
72
27
42
3
Ca pancreas
43
13
30
9
8
0
0 1'
Ca penampullary region Ca gallbladder
5
Secondaries· in
4
0
4
0
135
49
81
5
porta hepatis Total
·Patient discharged himself from hospital against medical advice.
were deemed incurable by resection, and palliative operations were carried out. There were 56 men and 25 women . Their ages ranged from 35 to 93 years, with a mean of 62.4 years . The sites and causes of the obstruction, the distribution of patients, and the nature of operations carried out are shown in Table 1. Palliative Operations for Malignant Obstruction of Bile Ducts The aim of these operations is to decompress the bile duct so that jaundice and pruritus may be relieved . This may be achieved by internal or external drainage or by a combination of both methods. For internal drainage, the site of the biliary tree available for decompression is dictated by the location of the obstruction, and may thus be gallbladder, common bile duct, common hepatic duct, left or right hepatic duct, or intrahepatic duct. The part of the gastrointestinal tract used for anastomosis to the proximal obstructed biliary system is usually a loop of jejunum, but sometimes the stomach or duodenum . Occasionally the gall bladder may act as an intervening organ between the right hepatic duct or its anteroinferior segmental branch and the jejunum. External drainage is by intubation, and this may be accomplished by a transhepatic tube (using a straight T or U tube), by a T tube placed in the common hepatic or common bile duct, or by a cholecystostomy. Often a combination of both methods is employed using a tube either as a temporary stent while an anastomosis heals over, or using a tube which traverses the site of malignant obstruction with side holes made in the proximal and distal parts of the tube to allow drainage of bile internally.
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CHD + CBD = UPPER & LOWER CBD = CHD + L. HD = CHD + L. & R. HD = TOTAL : 72
5 1 2 3
FIGURE 1· D1stnbut1on of 72 pnmary carc1nomas of the bile ducts. C ; Common , B ; B1te, H ; Hepatic, D ; Duct . L ; Left , R ; Right.
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WONG ET ALII TABLE 2
Cause of Obstruction. Operations Performed, and Survivors
Ca Bile Duct
Ca Gallbladder
Ca Pancreas
Secondanes in
Porta Hepatls Procedures
No. of Patients
Cholecystjejunostomy
No. Of Patients
Survivors
2
Survivors
10~
5
No . of Patients
Survivors
No . of Patients
Survivors
Cholecystantrostomy CholedochJejunostomy
7( 1)'
4
Choledochoduodenostomy
6
5
Choledochoantrostomy
3(1)
2
5( 1)
3
Hepaticojejunostomy
3
2
longmire operation
5
3
0 0
Cholangiojejunostomy Rt cholarlgiocholec ysto stomy
1t
Rt cholangiocholecystostomy With cholecystjejunostomy
1
10(1)
6
tOt
6
Cholecystostomy
2
Intubation. transhepati c T Tube : Through tumour above tumour
2 0
2 1
1 0
17
5
3
3
Total
43
30
28
3
One patient had both proce dures. One pat1ent had tripl e anastomoses. Number 10 brackets shows leakage of biliary-entenc anastomosis . Anastomotic leakage contributory to death .
··survivors'" refers to patients who lived beyond 30 days.
periphery of the liver, the duct having been isolated after amputation of the left or right liver edge. Table 3 shows the different causes of obstruction, the mean period of survival of patients who lived beyond 30 days after the operation , and the incidence of relief of symptoms . A number of patients were relieved of jaundice and pruritus after operation, although they did not survive beyond 30 days.
RESULTS
The distribution of 72 primary carcinomas of the bi le ducts is shown in Figure 1. The types of palliative procedures performed for each condition, the number of patients operated on, and the number of survivors, are shown in Table 2. Hepaticojejunostomy refers to anastomosis of a jejunal loop to the hepatic ducts in the porta hepatis. Cho langiojejunostomy or cho langiocho lecystostomyy refers to anastomosis of the jejunum or gall bladder to an intrahepatic duct not located in the edge of the liver. Longmire operation refers to jejunum anastomosis to an intrahepatic duct at the
For the who le group of patients, the operative mortality (within 30 days of operation) was 30 out of 81 (37%) . The causes of death were usually multiple and consisted of malignant cachexia, hepatic and
TABLE 3 Cause of ObstructiOn and Resulls of Operation
Mean Period No. of Pat1ents
Survivors
(months)
Relief of Symptoms
Ca bile ducts
42
28 (67%)
3.9
28 (67%)
Ca pancreas
30
17 (57%)
3.1
21 (70%)
5
3 (60%)
4.0
3 (60%)
3 (7 5%)
53
3 (75%)
51 (63%)
37
55 (68%)
Conditions
Ca gallbladder
of Survival
Secondanes tn
porta hepa11s 81
Total
'"Surv1vors'" refers to pa t1 ents who lived beyond 30 days
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renal failure, gastrointestinal bleeding, and pneumonia. Leakage from biliary-enteric anastomosis was not a serious problem in our series of patients. There were four patients with anastomotic leakage, and in one patient this complication was contributory to death (Table 2). In the other three patients, bile leakage stopped within two weeks without further operation . The mean survival period of the survivors was 3.7 months, one patient living for 18 months before succumbing from metastasis. Relief of symptoms was obtained in 55 out of 81 (68%) patients after operation. Of the remaining 26 patients, 10 (12%) were not relieved of their obstruction, and 16 (20%) died in the early postoperative period, so that the result could not be assessed. Three patients who underwent internal drainage procedures not commonly described are presented . CLINICAL RECORDS CASE 1.- This patient was a 25-year-old Chinese labourer who presented with one month 's history of repeated attacks of dull upper abdommal pain and jaundice. A hard lymph node one centimetre in diameter was found 1n the lett supraclavicular fossa The liver was not enlarged . Investigation showed biochemical evidence of biliary obstruction . A preoperative percutaneous cholangiogram revealed dilated mtrahepatic ducts, but the extrahepatic ducts were not visualized . At operation, a large cancerous mass was found in the porta hepatos woth direct infiltratoon mto the liver substance. Exploration in the region of the porta was therefore not attempted. Dissect ton was commenced in the right free margon of the liver and dtrectly into the liver substance. A small duct of the right lobe was isolated . and after some difficulty a portion of the duct one centimetre in length was freed . A small tube was inserted into the duct and fixed by a suture . A Roux-en-Y loop of upper jejunum was anastomosed to the capsule of the liver, with the duct lying free in the jetunum. The tube stent was brought out through the jejunal loop and then through the anterior abdominal wall.
After operation the patient did well and his liver function rapidly inproved. A retrograde cholangiogram performed two weeks after operation showed decompression of the intrahepatic duct, drainage of contrast medium into the jejunal loop, and no evidence of leakage (Figure 2) . Chemotherapy was commenced three weeks after operation, and he remained well and asymptomatic for four months before dying of metastic disease. CASE 2. - This 63-year-old Chinese housewife was admitted to a hospital in Smgapore with a four-month history of a mass in the right upper abdominal quadrant, jaundice, and pruritus. Investigations showed progressive obstructive jaundice, and an operation was performed in August 1976. At operation the liver was found to be enlarged, but the commo n bile duct and gallbladder were not distended. Exploration of the common bile duct showed obstruction of the upper part of the common hepatic duct. The stricture was dilated and biopsy carried out. A T tube was Inserted with the upper limb traversing the stricture. It was considered that she was suffering from carcinoma of the common hepatic duct, although the b1opsy specomen taken at the operation did not show malignancy. Initially she was relieved of her jaundice and pruritus, but a month later her symptoms returned and she was transferred to Hong Kong for further management. On admission. she was moderately jaundiced and a four centimetre non- tender hepatomegaly was palpable. Reoperation was performed in November 1976. There was ascites, and the lover was enlarged and congested . A deepsea ted large tumour mass was felt at the dome of the right lobe. Exploration of the common bile duct through the previous choledochotomy site confirmed the presence of obstruction of the upper common hepatic duct dnd the left and right intrahepatic ducts. The gall bladder was mobilized from its bed. and the anteroonferior segmental duct was found by dissecting into the liver substance of the gallbladder fossa . A two centimetre segment of this duct was exposed , and a side-to-side intrahepatic cho langiocholecystostomy was performed using one layer of onterrupted fine catgut over a small Portex catheter. The catheter was then brought to the exteroor through a cholecystotomy . A cholecyst1ejunostomy was not deemed necessary, as the sote of obstruction wa& intrahepatic. The left duct was dilated and a transhepatic tube placed woth one end in the common bile duct and the other end traversong the tumour and brought out through the surface of the left lobe of liver and then to the exterior. A number of holes were cut 1n this tube 1n the ontrahepatic portion, so that internal drainage could take place when the tube was clamped . Her condition did not warrant a second internal drainage procedure on the left lobe. After operation, there was progressive alleviation of her symptoms and improvement on the results of liver function tests . A retrograde cholangiogram through the cholangiocholecystostomy tube showed decompression of the nght hepatic duct system (Figure 3) , and the tube was removed . A cholangiogram through the transhepatic tube showed a decompressed left duct system and flow of contrast medium into the duodenum . The left transhepattc tube was left 1n s1tu. She rema ined well and gained 15 kg on weight over the next 6 months. However, it was decided to reoperate on thos patoent for two reasons: first , to establish a pathological diagnosos; and second , to determine of an internal drainage operatoon was necessary for the left lobe.
FI GU RE 2: Case 1; retrograde cholangiogram through cholangtOJelunstomy tube, showong decompresljoon of the ontrahepatic biliary system and flow of contrast medium onto the 1e1unum
506
At operat1on the liver was found to have become smaller and less congested . The mass felt on the dome of the right lobe was unchanged. The prevoous cholangoocholecystostomy was palpated through the wall of the gallbladder and was found to be patent. Transhepatic biopsies and boopsoes of tossue at the porta were carried out , and frozen section exam1natoon revealed mucin-secreting adenocarcinoma. The common bile duct was opened and the left transhepatic tube removed . Probing of the left hepatic duct showed 11 to be widely patent It was then dec1ded not to perform Internal dra1nage. A T tube was mserted in the common bile duct with the upper lomb
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FIGURE 3: Case 2: retrograd e cholangi ogram th rough the cholangiochole cystostomy tube showing patency of the anastomosis and visualization of the right intrahepatic biliary system. The site of the hepatic duct obstruction is some distance from the cysti c duct junction to the common bile duct.
traversing the site of the previous stricture of the left hepatic duct. After operation her convalescence was uneventful. A retrograde cholangiogram after ten days showed the lett duct system to be normal in calibre, and contrast medium flowed freely into the duodenum . The T tube was removed on the 14th day. Six months after this operation and twelve months after her f1rst operation in Hong Kong, she remamed well and asymptomatic. CASE 3.- This 75-year-old Chinese housewife was admitted to hospital in June 1977 in shock from upper gastrointestinal bleedmg . She had been a diabetic for two years and was being treated with oral hypog lycaemia drugs. Immediate gastroduodenoscopy showed active bleeding from a chro nic duodenal ulcer. Emergency operation was carried out , and a :we-centi metre posterior wall c hronic ulce r was found in the lrst part of th e duodenum w1th act1ve bl eed ing from the gastroduodenal artery. In addition, empyema of th e gallbladder, was present, with two stones in the gallbladder one of Which was 1mpacted in Hartmann's pouch. The bleeding site was Plicated and truncal vago tomy and Heineke-Mikulicz Pyloroplasty were performed. Cholecystostomy was carried out after removal of the two stones. Three weeks after operation she became jaundiced and began vomiting after meals. A retrograde cholangiOgram via I he cholecystostomy tube showed obstruction of the common bile du ct with proximal duct dilatat ion and no contrast medium entenng . the duodenum (Figure 4). Banum meal X-ray exammat1on revea led obstruction at the dis tal portion of the first part of the duodenum. Carcinoma of the pancreas was suspected and reoperation was performed . At operation a mass was found 1n the head o f the pancreas , and frozen sectio n examination of a biopsy specimen showed adenocarcinoma . Cholecystectomy was performed, and the dilated common hepatic duct was divided and the lower end closed . Th e first part of the duodenum was then divided and the
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FIGURE 4: Case 3; retrograde c holangiogram through cholecystostomy tube showing dilated com mon hepatic and intrahepatic ducts. There is obstruction to flow of contrast medium beyond th e junction of the cystic duct and the common bile duct. distal end closed. The proximal common hepatic duct was then anastomosed end-to-end to the duodenum by one layer of interrupted catgut sutures over a latex )ube , one end of which was brought out through the anterior wall of the stomach and then through the abdominal wall . An antecolic gastrojejunostomy was constructed . She made a good recovery after this operation, and a cholangiogram via the transgastric tube showed patency of the anastomosis with decompression of the biliary tree (Figure 5) . Results of her liver function tests returned to normal, and she was able to eat a standard ward diet without discomfort. She rema1ned well and asymptomatic for five months after her second operation before dying of metastatic disease. DISCUSSION
For malignant obstruct!on of the bile duct, the only hope for cure is by resection . Although this form of surgery is possible in more than half of patients with periampullary carcinomas (Douglass, 1974; Makipour et alii, 1976; Wise et alii, 1976; Nakase et alii , 1977), it is usually not applicable to malignancies of the bile duct, gallbladder and pancreas, or obstruction by malignant lymph nodes in the porta hepatis (Thorbjarrason , 1959; Braasch et alii, 1973; Fortner et alii, 1976; Nakase et alii, 1977). Radical surgery In malignant obstruction of the bile ducts should thus be reserved for the small number of selected patients who have genuine 507
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AGURE 5: Case 3; retrograde cholangiogram through transgastr1c tube show1ng patency of end-to-end choledochoduodenal anastomosis with decompression of the biliary system .
prospects of cure (Warren et alii, 1975; Wise et alii, 1976; Tompkins et alii, 1976). In the majority of patients, only palliative procedures are appropriate. Carcinoma of the bile ducts has been the cause of obstruction in over half of our patients. We have included carcinoma of the lower end of the common bile duct in this group, and this may account for the relatively large numbers as well as the high resection rate as compared with that in other series (Braasch et alii, 1967; Ross et alii, 1973). Another explanation for our high incidence of bile duct cancers may be related to the prevalence of clonorchiasis in our patients . Our operative mortality for palliative operation of bile duct carcinomas is 14 out of 39 (36%) , and is similar to that reported by Ragins et ali1 , (1973), Ross et alii, (1973) and Fortner et alii (1976) . Because of the frequency with which carcinoma of the bile duct is situated at the junction of the common hepatic duct with the left and right hepatic ducts (a finding similar to that in the series reported by Braasch et alii, (1967), palliative internal drainage has required intrahepatic ductal anastomosis to the jejunum , or anastomosis of the right hepatic duct or its anteroinferior segmental branch to the gallbladder, usually with a cholecystjejunostomy. We have, whenever possible, attempted internal drainage for high ductal carcinomas, and have been impressed with the palliative value of the right intra hepatic cholangiocholecystostomy, even when there is no apparent communication between the left and right hepatic ducts. Our experience with intubation has not' been as favourable as with biliary-enteric drainage, as
508
frequent episodes of cho langitis are the lot of many of these patients, a few of whom have required reexploration for decompression or conversion into an external fistula. However, some patients with intubation have had adequate symptomatic relief, and one patient was alive and symptom-free over one year after intubation. Similar resu lts were reported by Klatskin, (1965). Whelton et alii, (1969) and Fortner et alii, (1976) . We did not find external drainage procedures to be attended by a high mortality rate as reported by Ross et alii, (1973) . Because of certain disadvantages of intubation, such as cholangitis, loss of bile, and the necessity for a permanent tube, we have whenever possible performed internal drainage in all patients except those who have been critically ill and unable to tolerate a longer operation . It is possible in virtually all patients with malignant bile duct obstruction to perform internal drainage so long as the patient's condition permits. For carcinoma of the head of the pancreas with a dilated common bile duct, satisfactory results have been obtained with end-to-end choledochoantrostomy , or choledochoduodenostomy and gastrojejunostomy, instead of the classical triple anastomosis . In some patients with carcinoma of the head of the pancreas with a distended gallbladder, cholecystjejunostomy may not provide adequate drainage, and in two such patients , reoperation to perform internal drainage via the common bile duct was required . For carcinoma of the gallbladder with obstructive jaundice, the cause is either local recurrence after cholecystectomy or extensive local primary disease with invasion of the bile ducts. Under these circumstances. palliative decompression may be obtained by a Longmire operation , a hepaticojejunostomy, or intubation. When biliary obstruction is caused by metastatic lymph nodes in the porta hepatis, internal drainage can be performed if the liver is free of extensive tumour deposits. If there are gross hepatic metastases or widespread abdominal disease, intubation alone would be indicated. It has been our practice to operate on all patients with obstructive jaundice, even when malignancy is reasonably certain to be the cause. because concomitant choledocholithiasis is common in our community and may be an additional cause of obstruction in some patients . Furthermore. symptoms of progress1ve jaundice and pruritus are not well controlled by drugs Therefore, in spite of a high operative mortal1ty, we believe that the better palliation enjoyed by those who surv1ve warrants operative treatment in patients with malignant obstruction of the bile ducts. A UST
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REFERENCES BRAASCH, J W .. WARREN, K. W. and KUNE, G. A. (1967) , S\Jrg. Clm. N. Amer.. 47 : 627 BRAASCH , J W (1973) , Surg. Clm. N. Amer., 53 . 1217. DoUGLASS , H 0 (1974) , Surg. Annu .. 6: 161 FORTNER, J . G., KALLUM, B.O. and KtM , D. K. (1976) , Ann. Surg .. 184 68. KLATSKIN, G. (1965) . Amer. J. Med.. 38: 241 MAKIPOUR, H., COOPERMAN , A .. DAN ZI, J . T and FARMER, R. G . (1976) . Ann. Surg .. 183· 341 . NAKASE, A ., MATSUMOTO, Y , UCHIDA , K and HONJO, I. (1977), Ann Surg.. 185. 52.
WONG ET ALII
RAGtNS, H ., DtAMOND, A ., and MENG. C . H . (1973). Surg. Gynec. Obstet ., 136: 27. ROSS, A. P., BRAASCH, J W. and WARR EN, K W (1973), Surg Gynec. Obstet .. 136: 923 THORBJARNARSON, B. (1959). Cancer. ( Phtlad.) 12 708 TOMPKINS R K , JOHNSON , J ., STORM, F K and LONGMIRE , W. P (1976), Amer. J Surg., 132: 174 WARREN , K. W . CHOE, D S , PLAZA, J . and RELIHAN, M . (1975) , Ann. Surg .. 181 · 534 WHELTON , M . J ., PETRELLI, M., GEORGE, P. (1969). Quart. J . Mad., 38: 211 . WISE, l , PI ZZIMBONO, C. and DEHNER, L. P. (1976). Amer J. Surg .. 131 . 141 .
RECURRENT BILIARY CALCULI DUE TO NON-ABSORBABLE CYSTIC DUCT LIGATURES DAVID INGRAM' AND DENIS G . KERMODE'
Queen Elizabeth II Medical Centre, Perth A non-a bsorbable cystic duct ligatu re may mig rate into the c ommon b!le du ct and ~ct as a ni du s lor recurrent sto ne fo rm ati on. Fou r case hi stories are presented and the pro blem Is dtscussed. Th ts seq uel may be pre_ven ted by the use of absorbable sutures to ligate the c ystic du ct, there by redu cin g the n umb er o f patients lactng the haza rd s of recu rre nt bil iary su rger y.
RETAINED and recurrent common bi l e duct stones are an importan t prob lem of bi liary surgery . The frequency of retained stones has been reduced by the routine use of ope ra tive cholangtography (Faris et alit , 1975) . In recent years , however. there has been an increasing number of reports (Mackie et alit. 1973: Mtllbourn . 1949; Ahlberg. 1959: S1gler and Sahler, 1969: Rees and Jacob . 1977: Anderson and Blumgart . 1978) of patients in whom recurrent stones have been found subsequent to the use of non-absorbable material to ligate the cyst1c duct. This complication is preventable by the use of absorbable t ies for the cyst i c duct. Four cases presenting under the care of one surgeon (D .G . K .) are reported . CLINICAL RE CORDS CASE 1 - A 55-year-old woman was admt tt ed to hospttal tn December 1971 She had had a cholecystect omy 18 months prevtously and over the lour months pnor to thts admtSStOn had three eptsodes ol severe eptgastnc patn . one ol th ese betng assoctated woth 1aundtce and pyrexta Ftndtngs on cltntcal • Surg1ca1 Reg1strar
' Surgeon
Repnnts Mr 0 G Kermodc FA West rn Australia 6005
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exammatton were normal at the ttme ol admtsston , but an tntravenous cholangtogram showed a filling defect at the lower end of the common bile duct. At operatton two silk ligatures surrounded by a friabl e mucotd stone were found and r mov d . CASE 2.- A 71-year-old man presented tn February 1972 wtlh a htstory of severe eptsodtc eptgastnc patn radtaltng between the shoulders. He had prevtously had a cholecystectomy and parttal gastrectomy tn 1943 On exammatt on he was febnle. tn patn , and Jaundtced There was marked tenderness tn the nght upper quadrant of the abdomen He had a leukocytosts of 16.400/ mm ' and results o f ltver fun c tt on tests tndtcated btltary obstructton. At operatton three large stones were removed from th e common btle duel . wht ch was three c~nttmetres tn dtameter A peroperattve postexploratory cholangtogram appeared normal. but hts postoperattve T-tub cholangtogram snowed a restdual stone . Thts was removed at a further operatton and was found to contatn a w1111e stlk ltgature ( Ftgure 1, upper) CASE 3 - A 45-year-old woman was admt\ted to hospttal tn Aprtl 1972 Wtth recurrent abdomtnal patn stnce a cholecys tectomy'" 1968. At that ttme her common btle duct was explored. but no stones were found She descnbed a classtcal btltary patn and desptte a normal tntravenous cholangtogram tt was thought that reexploratton was warranted Thts revealed a large cysttc duct stump with a stlk ltgature lytng free wtlhtn thts stump No stones were present (Figure 1. lower) . CASE 4- A 44-year-old woman was admttted to hospttal tn June 1977 w tth an attack of nght upper quadrant abdomtnal patn whtch radtated to her back. She had had a similar attack three months prevtousty , and she descnbed the patn as stmtlar
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