Abstract

Prof (Dr) Ajaz Ahmad Malik, Dr. Yaqoob Hassan*, Dr. Ifat Irshad, Dr. Mohd Lateef Wani, Dr. Ishfaq Ahmad Wani

ABSTRACT

Background: Since with widespread availability of ERCP and liberal use of endoscopic sphincterotomy, more and more surgeons feel comfortable in performing primary closure which significantly reduces the hospital stay. There is however still the apprehension of a greater incidence of bile leak and post-operative cholangiogram is not possible. Therefore primary closure over an ENBD (endonasobiliary drainage) tube was attempted to overcome this difficulty. Patients and methods: This prospective comparative study for 6 yrs (Jan 2007- Dec. 2012) comprised of 54 patients –having primary closure of the common bile duct (CBD) over endonasobiliary (ENBD) tube (Group 1) and 50 patients –having primary closure of the common bile duct (CBD) alone (Group 2) All these patients had been taken for surgery after failed attempts at endoscopic retrieval. Preoperatively, both the groups were comparable in terms of clinical and investigational parameters. No patient in the study had cholangitis. The only notable difference in the two groups was in the method of preoperative ductal drainage. Results: Mean age in Group 1 was 42.34 years and in Group 2 was 41.38 Years. Females outnumbered males in both the group. CBD size in ENBD group was 1.45 + 0.42 and in primary closure alone group was 1.46 + 0.29. Eleven patients in primary closure group, while only six patient in the ENBD closure group had solitary stones. Worms were detected in one patient in each group. Wound infection was found in two patients in ENBD group and in one in primary closure group.The ENBD tubes were removed by the 6-7 day in 80% of patients and by the 8th day in all. Patients in the Primary closure group were on average discharged 1-2 days earlier than those in the ENBD group. Conclusion: Primary closure of the common bile duct alone is safe and acceptable after choledocholithotomy with only a slight risk of bile leak, however postoperative cholangiogram cannot be performed. Primary closure over ENBD is safe and effective after choledocholithotomy. Additional advantages like cholangiograms and contact dissolution for retained stone can be tried.