The most frequent cause of trauma to the papilla are attempts to dilate the papilla, may lead 10 false tracts. The false tract may occur mer the duodenum or the pancreas.
The surgeon who is attempting to pass the papilla with the dilator perforates the common bile duct entering the duodenal lumen believing he or she has done so through the papilla and then continues lo pass dilators of progressively greater diameter, believing the papilla is being lated when in fan it is the false tract produced by the surgeon.
A more serious and at times mortal false tract occu rs when the explorer perforates the inferior common iile duct into the pancreatic parenchyrna. The appearince of bile on the surface of the pancreas is indicative this complication and should be confirmed with an operative cholangiognrm.
It is very important that the surgeon realize char he or she has produced a false 1 ract in order to try to correct it during the surgical pro ccdure, since not doing so may lead to Joss of the patient's life.
If the surgeon realizes that he or she has a false tract into the pancreas, he or she should immediately proceed to transect the common bile duce closing the distal end and arusromostng the proximal end of the common bile duct or preferably the hepatic duct to a jejuna loop in RouxenY fashion. Before abdomen dosed, a suction drainage tube should be placed under the liver for 5 to 6 days.
A false tract into the lumen of the duodenum carries less serious complication and in many cases not recognized although it occurs more frequently than a false tract into the pancreas.
Final Control Cholangiogram
Once the calculi have been removed from the common bile duet and till instrumental exploration and choledochoscopy have been performed, a ltube is placed in the common bile duct. The final operative control cholangiograrn is performed with the Ttube in place, with the object of verifying that all the calculi have been removed and the radiopaque substance passes readily into the duodenum.
If the cholangiogram reveals that the mon bile duct is free of calculi and the radiopaque substance passes normally into the duodenum.ithe surgical procedure is terminated, leaving a dosed suction drainage tube in the foramen of Xrinslow and closing the abdominal wall. If on the contrary, the control cholangiograrn reveals that there are residual calculi, the Ttube is removed and the calculi seen in the cholangiogram are removed.
The Tcube is again replaced in the common bile duct and a new cholangiogram obtained to he sure that all calculi have been removed. The surgeon should never leave a stone behind if at all possible, except in cases in which the patient's condition does not perrnlt conttnuation of the operation or the calculi are located in a duct from which they cannot be removed (usually intraheparic).