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INTERNATIONAL JOURNAL OF SCIENTIFIC DEVELOPMENT AND RESEARCH International Peer Reviewed & Refereed Journals, Open Access Journal ISSN Approved Journal No: 2455-2631 | Impact factor: 8.15 | ESTD Year: 2016 open access , Peer-reviewed, and Refereed Journals, Impact factor 8.15 |
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| Paper Title: | WHY PRIMARY CBD CLOSURE IS STILL AN TABOO |
| Authors Name: | DR SHREE VENKATESAN.B , DR KALAISELVI.P , DR ASHIQ AHMED.A , DR P.THANGAMANI |
| Unique Id: | IJSDR2301200 |
| Published In: | Volume 8 Issue 1, January-2023 |
| Abstract: | ABSTRACT: CBD exploration followed by T-tube insertion has been the primary practice in hospitals without laparoscopy expertise as it prevents future complications like obstructive jaundice(secondary to retained stone or stricture) .However over several decades various authors have shown that primary closure of CBD without T Tube proven to be beneficial when compared to that of T tube insertion and also avoids potential complication of peri-tubal leak and iatrogenic stricture formation LEARNING OBJECTIVE: To reiterate that primary closure of CBD can be achieved safely without T-tube insertion without significant post op complications. INTRODUCTION: Chloledocholithiasis develops in about 10–15% of patients with gallbladder stones and that of common bile duct (CBD) stones are encountered in approximately 7–15% of patients undergoing cholecystectomy. There are two methods for extracting CBD stones either endoscopically, by endoscopic retrograde cholangiopan creatography (ERCP), or surgically, by an open or laparoscopic method. The advancement in laparoscopic and endoscopic techniques has almost made open biliary surgery obsolete. However even now in resource poor countries due to lack of training as well as equipment, many surgeons are commonly required to perform open cholecystectomy and CBD exploration for choledocholithiasis. Open exploration of the bile duct was the principal treatment for almost 100 years.Choledochotomy followed by T-tube drainage is atraditional surgical treatment for chloledocholithiasis. Although it is true that the T-tube has been used and has proven to be a safe and effective method for postoperative biliary decompression, it is not exempt from complications, which are present in up to 10% of patients. The most frequent of these is bile leakage after removal, which is reported to occur in 1–19% of cases.Some of these complications are serious, such as bile leak, tract infectionor acute renal failure from dehydration due to inadequatewater ingestion or a very high outflow, particularly in elderly patients. In addition, having bile drainage in place for at least 3 weeks causes significant discomfort in patients and delays their return to work. Primary closure of the CBD after exploration is not new. “Halstead et al”(1) first described the advantages of primary closure. There are many papers reported by different authors, which support the direct closure of the duct immediately after exploration. With the help of a choledochoscope or intra operative cholangiogram during surgery, primary closure is possible with almost certainty of removing stones As early as 1965, “Sawyers et al”(2). documented the advantages of primary closure of the CBD and recommended that routine use of a T-tube following CBD exploration be abandoned . In the only report from the Caribbean, “Walrond et al(3)” recommended that T-tubes should not be used . In two Cochrane reviews, one each for open and laparoscopic biliary surgery, the authors were inconclusive regarding the benefits and safety of T-tubes . However, in many places, routine use of a T-tube following CBD exploration remains standard practice. T-tubes are associated not only with prolonged hospital stay and complications such as retained stones, retained T-tube fragments, inflammatory polyps, sepsis, tube dislodgement, bile fistula, biliary stricture, bile leakage and peritonitis .Open biliary surgery, CBD exploration and drainage with primary closure of the CBD can be safe in experienced hands and is specifically useful in a limited resource setting. In our hospital, open CBD exploration is still the treatment chosen for CBD stones. In this case series, our aim was to highlight the clinical short-term results of primary closure of CBD and reiterate the fact that it is safe to do this procedure. CASE SERIES 1.Mrs Rani,65 yr,comorbids-.T2dm, Presented with right hypochondriac pain x 20 days Investigations:T.billirubin-2.6,D.billirubin-1.5,ALP-545 Mrcp –cholelithiasis with choledocholithiasis of size 1.4cm at distal cbd with upstream dilatation of 1.3 cm of CBD 2.Mrs Kalaivani,39/F c/o diffuse abdomen pain x 3 months ,especially after meal. Admitted for biliary pancreatitis. Investigations:T.billirubin 3.6,d.billlirubin 1.8,Alp 560 Amylase 390,lipase 420 MRCP:multiple gb calculi largest 6.5x7mm,multiple mid and distal cbd calculi size 4-5 mm and proximal cbd dilatation 7.3mm. Proceeded with interval cholecystectomy and cbd exploration Intraop findings:multiple stones retrieved. 3.MrsTamil,54/F c/o abdomen pain x 10 days,radiating to back past history:partial cholecystectomy in 2003 comorbids:t2 dm Mrcp:cholelithiasis 1 x0.7 cm in cystic duct and choledocholithiasis 0.7x0.6cm in distal cbd with proximal cbd dilatation of 1.4 cm ERCP stenting done . Intraop cbd fibrosis was present DISCUSSION From the 3 patients that we have encountered over the period of 6 months from jan 2022 to September 2022 ,we have encountered similar yet distinct cases that posed us unique challenge like post cholecystectomy retained cystic duct calculi ,multiple cbd calculi with cbd fibrosis ,yet primary closure as attempted after careful anterior trans choledochotomy approach.cbd calculi were flushed out carefully until no more calculi was obtained ,those which were large enough to be flushed was carefully removed with Desjardins.patency of cbd confirmed with feeding tube saline flushing .intraop cholangiogram not done in all 3 cases.post operative period was uneventful,patient recovered well and rt sub hepatic dt placed for all 3 cases were removed 6,6,7 post operative date respectively.bicochemical parameters were within normal range.post op followup after 1 month was uneventful and patient satisfaction in terms pain and functionality was satisfactory. RESULTS: From our experience we have found that primary cbd closure is possible with on-table intra-abdominal usg,saline flushing of cbd with saline via feeding tube as an adjunct to on table cholangiogram .yet there has to be an consensus among new surgeons to forego T Tube placement whenever and wherever possible . |
| Keywords: | cbd exploration,primary cbd repair |
| Cite Article: | "WHY PRIMARY CBD CLOSURE IS STILL AN TABOO ", International Journal of Science & Engineering Development Research (www.ijsdr.org), ISSN:2455-2631, Vol.8, Issue 1, page no.1251 - 1255, January-2023, Available :http://www.ijsdr.org/papers/IJSDR2301200.pdf |
| Downloads: | 000337072 |
| Publication Details: | Published Paper ID: IJSDR2301200 Registration ID:203812 Published In: Volume 8 Issue 1, January-2023 DOI (Digital Object Identifier): Page No: 1251 - 1255 Publisher: IJSDR | www.ijsdr.org ISSN Number: 2455-2631 |
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