This maneuver can be repeated as many times as necessary until choledochoscopy and operative cholangiograrn reveal chat there are no further calculi in the common bile duct. If in spite of all these measures a calculus is found in the cholangiograrn performed postoperatively, this calculus can he removed through the fistulous tract formed by the long limb of the trube.
This b the procedure of choice for the great majority of surgeons when treating multiple stones in the common bile duce. However, when calculi are very numerous some surgeons after removing calculi in a systematic form, do a choledochoduodenostomy or a sphincteroplasry as a method of treatment in case a calculus has been retained or calculi reform in the common bile duct. The author believes, as other surgeons, that these prophylactic measures increase the mortality and morbidity rates even in experienced hands.
It is logical to think that these figures will be even higher in less experienccd hands. The author believes that bypass procedures between the biliary and digestive tract or sphinctcroplasty should be indicated in cases of stricture of the sphincter of Oddi, in stricture of the retropancreatic duct, or in those patients in whom the surgeon is sure be or she has left calculi in the common hile duct because he or she could not remove them.
These calculi have very typical morphologic characterisics. According to some authors, primary cal culi develop when Chere is biliary stasis, particularly in romrnon bile ducts that are dilated. Ocher authors admit thar calculi can develop without there being any biliary stasis.
Some surgeons maintain that primary calculi of the rommon bile duct are frequent in occurrence and therefore advise chat a choledorhoduodenosromy or a sphinctcroplasty be performed in these cases to prevent the frequent recurrences of primary common duct lithiusis. Other surgeons, however, believe that cholcdochoduoccnostomy and sphincteroplasry should only be used in patients with primary lithiasis who have fibrosis of the sphincter of Oddi or stcnosis of the retropancreatic common bile duce.
The choice between a cholcdochoduodenal anastomosis and a sphincteroplasry depends on several factors:
- Caliber of the common bile duct.
- Age of the patient.
- Srricrure limited tO the sphincter of Oddi.
- Stricture extending proximal to the sphincter of Oddi.
- Stenosis of the retropancrearic common bile duct.