How should the common bile duct be explored?

An attempt has been made to find which of 3 operations currently in use for exploring the bile ducts gave the best clinical results. For this purpose 3 series of consecutive patients treated at The London Hospital over a 12-year period have been studied retrospectively. The operations used were as follows: (1) conventional supraduodenal choledochotomy; (2) transduodenal biliary sphincterotomy; and (3) a combined approach. The mortality in the supraduodenal series was 4 (4%) of 101 patients and in the transduodenal series 2 (2.4%) of 82 patients. Both routes were used in 26 patients, of whom 2 (7.7%) died. Early complications were commoner after choledochotomy than after biliary sphincterotomy, but when both procedures were combined the incidence was higher still. Late complications were also more frequent after both the supraduodenal and the combined approach, residual or recurrent stones and cholangitis being 6 times more common than after sphincterotomy alone. Postexploratory cholangiography, however, was not used routinly in the supraduodenal series and might conceivably have reduced this factor further, but not below 3. Stenosis occurred in one patient after choledochotomy and in one patient after the combined operation but not after sphincterotomy alone. In this study, therefore, transduodenal biliary sphincterotomy gave the lowest mortality and morbidity. With the combined procedure, however, the mortality and morbidity were much higher than after either method alone.