Definitive decompression of the biliary tree-preferred approach to management of choledocholithiasis and/or associated pathology.
The experience of the senior author in the management of biliary tract lithiasis and/or associated pathology is analyzed, retrospectively until 1976 and prospectively from then on, in an attempt to ascertain the most efficient manner of handling a duct requiring surgical exploration. Primary surgery was done on 245 patients, while 22 common bile duct reoperations were carried out on 20 patients. In the primary surgery group, 177 simple cholecystectomies were undertaken, and an indication for duct exploration was present in the other 68. Out of 90 common bile duct explorations, 68 primary ones plus 22 reoperations, two operative deaths occurred (one in each group). Fifteen patients had a choledocholithotomy with temporary T-tube decompression, with "normal' postexploratory and predischarge tube cholangiograms. Six of these (40%) required reoperation (recurrent stones in three, residual calculus in two, stenotic papilla in one). Of 70 ducts definitively drained (60 choledochoduodenostomies, nine sphincteroplasties, one Y-loop hepaticojejunostomy) only one (1.4%) of the patients who had a sphincteroplasty has had an episode of jaundice and cholangitis, a highly significant difference (p = 0.001). This experience suggests that a correct biliary fenestration, permanently decompressing the biliary tree, performed during the initial operation will avoid many unnecessary hospital admissions and should, therefore, be seen as the procedure of choice in the overwhelming majority of situations when a pathological common bile duct is encountered.