Multiple bile duct stones: Comparison of two surgical techniques done at laparotomy.

Background: Biliary lithiasis is the most common surgical disease in Tunisia. Multiple bile duct stones are one of his most rare complications.It poses real problems with the best therapeutic approach.

Aims: To analyze the results of conventional surgery for multiple bile duct stones by comparing two techniques: The choledochotomy for stoneextraction followed by external biliary drainage and biliary-enteric anastomosis, to identify and to analyze the factors influencing the therapeuticchoice.

Methods: During study period spanning 16 years, 137 choledochotomy were made for multiple bile duct stones. These patients had either acholedochotomy with stone extraction and then drained through a T-tube or a biliary-enteric anastomosis.

Results: Preoperative diagnosis of multiple bile duct stones has been made in 32.1 % of patients. Cholangiography was found in all casesmultiple bile duct stones and had demonstrated an association with intrahepatic stones in 18.2 %. External drainage by a Kehr drain wasperformed in 39.4 % and biliary-enteric anastomosis in 60.6 %. Univariate and multivariate analysis had identified three factors significantlyassociated with external drainage: age ≤ 65 years, bile duct diameter < 15 mm and the existence of a pronounced inflammatory reaction of thecholedochal wall. No factors had influenced the choice between different bilio-enteric anastomosis techniques. These three techniques did notdiffer from the post operative morbidity (p = 0.84) or mortality (p = 58).

Conclusion: Basing on the analysis of our series and the comparison with other series reported in the literature, we recommend biliary drainagewith a T-tube in young people under 65 years who have a little dilated bile duct, not exceeding 15mm. In patients aged over 65 years or thosewith a CBD dilated more than 15 mm, even with intrahepatic stones, in cases of distal bile duct stricture or periampullary diverticulum, biliaryentericanastomosis seems to be the safest technique.