HIKASA, YORINORI

KAMATA, TOSHIO

MARUYAMA, KEISUKE

MUKAIHARA, SUMIO

NAGASE, MASAO

SETOYAMA, MOTOICHI

TAKENAKA, MASAFUMI

TANIMURA, HIROSHI

Kyoto University Research Information Repository

Title Primary Closure of the Common Bile Duct after Explorationfor GallstonesAuthor(s)NAGASE, MASAO; TANIMURA, HIROSHI; TAKENAKA,MASAFUMI; SETOYAMA, MOTOICHI; MUKAIHARA,SUMIO; KAMATA, TOSHIO; MARUYAMA, KEISUKE;HIKASA, YORINORICitation日本外科宝函 (1978), 47(1): 90-93Issue Date1978-01-01URL http://hdl.handle.net/2433/208246RightType Departmental Bulletin PaperTextversionpublisherKyoto UniversityArch Jap Chir 47 (1), 90～93, Jan., 1978 Primary Closure of the Common Bile Duct after Exploration for Gallstones MASAO NAGASE, HIROSHI TANIMURA, MASAFUMI TAKENAKA, MoTOICHI SETOYAMA, SuMro MUKAIHARA, TosHIO KAMATA, KEISUKE MARUYAMA and YoRINORI HIKASA The 2nd Department of Surgery, Kyoto University, School of Medicine Received for Publication Nov. 9, 1977 I. Introduction Many authors have recommended choledochal drainage after common duct exploration for gallstonesll2>3＞的.The present authors, however4>7】9l10i rn, have recently attempted primary closure of the common duct in selected cases and have gained good results without any adverse outcomes. II. Clinical experiences In Table 1 are shown the kinds and sites of gallstones obtained from 2, 144 cases operated on at the 37 affiliated hospitals of the Department of Surgery Kyoto University School of Medicine during the last 20 months5>. Cholesterol stones which are most frequently seen in present Japan are predominantly situated in the gallbladder alone. Among these Table 1 Kinds and sites of gallstones at 37 hospitals ~ Kinds I cholesterol ・ bin 同｜~ I I Total C%) Sites ~ I stones s s I GB I 13凶 1s5 111 I 1605 c14.9) GB & CBD CBD 179 28 160 159 11 2 350 (16.3) 189 c 8.8〕Total （%〕 1510σ0.4) 504 (23.5) 130 (6心 I 2144 oo.o) GB: gallbladder, CBD : common bile duct Table 2 Frequency of choledochotomy and external choledochostomy in the 2,144 cases Choledochotomy・・ ・ ・ ・H ・－…..・ H ・..・ H ・－・…－…・537cases T-tube drainage …・ H ・H・..・ H ・H ・H ・..・ H ・－… 412(76.7~幻Primary closu問。fcommon bile duct・・・ ・H ・・125(23.3%〕Sites of gallstones Gallbladder ・ ・ ・ H・－…..・ H ・..・ H ・－… 54Gallbladder and common bile duct …531 > 71 Common bile duct ・H ・H ・－ －－…・ …… 18) Key words : Tube drainage, primary closure, Cholesterol stone Present address : Secod Department of Surgery, Kyoto University, School of Medicino. Sakyo-ku, Kyoto, 606 Japan. PRIMARY CLOSURE OF THE COMMON BILE DUCT 91 2, 144 cases, 537 cases underwent choledochotomy for common duct exploration, and in 412 cases (76. 70右） the common ducts wer巴 drainedwith T-tubes, while in 125 cases (23. 3%) including 71 cases with common duct stones the common ducts were closed primarily with absorbable suture materials (4-0 or 5-0 Deoxn町（Table2). Their postop巴rativecourse was almost always uneventful. Ill Data from enquete on surgery for choledocholithiasis Enquete on surgical techniques for choledocholithiasis was collected from 163 surgical clinics in Japan. As shown in Table 3, 102 surgeons (63%) drain routinely ev巴ryincis巴dcommon duct regardless of presence or absenc巴 of common duct stones. However, 51 surgeons (31%) decide whether or not to drain the common duct according to kinds of stones and to condi・tions of the bile ducts. The conditions which are considered to indicate choledochotomy Table 3 Choledochal drainage after choledochotomy 1) In al cases…・… υ …・ ・…・・ －ー－－－－－ .・ H ・....ー・…・.........…－一 102(633旨〕2) In al cases with common bile duct stones ・ ・ .・H ・－－－…－－－－－－….. . . 7 c 4%) 3) Accordmg to kmd of stones0・……………………………………………・・ …田・・…－ 4) I 51 4〕Accordingto c。n吋d1ti5) According to kind 。fstones and conditions 。fbile ducts ............ 22) 6) In no cases . ・H ・－－－－……………………・・ ・ …・ ・…………・・ 一.....… ・ー ー… 2 7〕Other .・ H ・－－－ － －－ －－・…・回一… …・・・・……… ・………………・・…...・ H ・ 1 From enquete on surgical techniques for choledocholithiasis, presented at the Second Japanese Meeting for Biliary Tract Surgery in Oct. 1977. Table 4 Indication of choledochotomy during surgery Findings of peroperative cholang10graphy －－－－－… ・田 ・・・ー・ー・・ 田a・一・0095.9%Macroscopic findings of biliary tracts ..…－－－－ －－－…司・… 一－ ・65.3% Patient’s history ...........・・・・・・・・一一・・ ・・ ・ー ・・・・ ・・・ ・ー一 回・・・・ ・46.5% Results of oparative biliomanometry ....... ・ . ・一 .......................21.2% From the enquete. Table 5 Operative findings indicating choledochotomy Diameter of common bile ducts more than 1 cm………－－ － ・・・ー ・ー ーー・ ・・ ・ー 一 － ・38.85'6 more than 1.5 cm………一一一一ー ・・・ー ．．．， …………ー…・…・…42.4%more than 2.0 cm・・・司…・・ ...・・ ・・・目・・・ー・ ・・ー ・ー ・・・ ・94% neglect …・ －……ー…・…ー・ 一－ ・・・ ・…...・ H ・－…・・ー…，…・ 9.4% Other findings Multiple small stones in the gallbladder . ・H ・H ・H ・－…..・ H ・－…一…31.8%Dilatation of cystic duct ・・……・・・・・ ・・・・・・・…ー・…・・・……－ － －・－－ － 一21.23旨Hard pancreas…..・ H ・－ ・……－ …・ ・…－ －…－…...・ H ・－・・田・…………10.6%From the enquete. 92 日外宝第47巻第1号（昭和53年1月）are listed in Table 4. Almost al surgeons decide whether or not to open the common ducts according to the findings of peroperative cholangiography. Among various operative findings, dilatation of the common ducts are considered the most important indication for choledo・chotomy (Table 5). As the tubes inserted into the common ducts, 156 surgeons employ T-tubes. And while 32 surgeons use slender tubes, 90 surgeons are inclined to use T-tubes of as large as possible, probably preparing for the non-operative extirpation of possible retained stones13>. IV. Discussion If there are biliary infection and stasis due to either stenosis or dilatation of the bile ducts and if there is any suspicion of retained stones, the common bile ducts should, of course, be drained with tubes, preferably with T-tubes of a possible large diameter. Since cholesterol stones are exclusively formed in the gallbladder8> 12>, cholesterol stones found in the common ducts must originate in the gallbladder and then migrate into the common ducts (secondary common duct stones). One may close primarily the common ducts after extirpation of cholesterol stones from the ducts, if he can be sure that no more stones are retained in the biliary tracts by means of peroperative cholangiography, choledochoscopy and so on, and if there are no remarkable changes in the bile ducts. By primary closure of the common ducts, any hazards resulting from external choledo・chostomy and extraction of the T-tubes can be avoided and duration of hospitalization can be curtailed considerably. Generally speaking, healing of any wounds by first intention (Sanatio per primam intentionem) is by far desirable than secondary healing. V. Conclusion Cholesterol gallstones predominantly seen in present Japanese people are exclusively formed in the gallbladder. When the stones extirpated from the common ducts are cholesterol stones, primary closure of the common ducts can be attempted, if there is neither suspicion of retained stones nor secondary changes of the bile ducts. The gist of this article was presented at the 39th Annual Meeting of Japan Practical Surgical Society held on 23rd October 1977 at Okayama. The authors wish to express their sincere gratitude to surgeons, who kindly answered to the enquete and whose names were listed in the program of The Second Japanese Meeting for Biliary Tract Surgery held on 17th October 1977 at Kyoto. References 1) Glenn F Atlas of biliary tract surgery. New York Macmillan 1963. 2) Maki T: Surgery of the liver, biliary tracts and pancreas. (written in Japanese) Tokyo Kanehara Shuppan 1974. 3) Miyake H : Cholelithiasis. (written in Japanese). Tokyo Kanehara Shuppan 1970. 4) Nagase M and Tanimura H et al : Etiology and treatment of choledocholithiasis〔writtenin Japanese〕.Arch Jap Chir 46 : 448-461, 1977. PRIMARY CLOSURE OF THE COMMON BILE DUCT 93 5) Nagase M and Tanimura H et al A collective reviw of 2, 244 cases of cholelithiasis. (in Japanese) Arch Jap Chir 46 : 740-747, 1977. 6) Schein CJ and Stern WZ et al : The common bile duct. Springfield Charles C Thomas 1966. 7) Tanimura H and Hikasa Y: Surgery and drainage of the biliary tract. (in Japanese〕Modernclinic 5 : 453-469, 1971. 8) Tanimura H and Hikasa Y : Cholelithiasis cholesterol stones. (in Japanese) Jap J Clin Med 30 : 234-241, 1972. 9〕 TanimuraH and Hikasa Y ・ Surgical treatment of cholelithiasis, especially gallstones in the common bile ducts. (in Japanese) Surg Diag Treat (Tokyo) 14 . 1271-1274, 1972. 10) Tanimura H: Operation for gallstones and cancer of the gallbladder. (in Japanese) Modern Therapy (Tokyo〕6・：399-404,1974. 11) Tanimura H and Hikasa Y et al: Indication of primary closure of choledochotomy after extirpation of the common bile duct stones. (in Japanese) Jap ] Gastroent Surg 9 : 554, 1976. 12〕 TanimuraH and Nagase M et al: Initiating factors of cholesterol gallstones and pancreatitis. Arch Jap Chir 45 3ー16,1976. 13) Takenaka M and Tanimura H et al : Operative cholangioscopy and nonoperative extirpation of the retained common bile duct stones. Proceeding of Xlllth Biliary Disease Assoc p. 86-87, 1977. 和文抄録胆石症手術における総胆管ドレナージの適応と，胆管の一期的閉鎖について京都大学医学部外科学教室第2講座長瀬正夫，谷村 弘，竹中正文，瀬戸山元一向原純雄，鎌田寿夫，丸山啓介，日笠頼則胆石症手術iζ際して総胆管を切開したのちには，原則として総胆管ドレナージを行なうというのが大方の意見であり，今回われわれが行なった全国的なアンケートの集計結果でも，総胆管結石の有無にかかわらず， T字管を入れるとするものが163施設中102と過半数を占めていた．しかし結石の種類や胆管の状態によってきめるとするものが51施設（31%〕あった．一方，著者らが関連病院から集計した胆石症手術2, 144例中，総胆管を切開したものは537例で，そのうち125例に総胆管の一期的閉鎖が行なわれていた．そのなかには胆管胆石のあった71例も含まれていた．現在わが国で最も多くみられるコレステローJレ胆石はもっぱら胆褒内のみで形成されるものであり，胆管内のコレステロール石は二次的胆管胆石である．したがって，術中，胆管から得た結石がコレステロール石であって，結石遺残のおそれがなく，また胆管lと著しい二次的変化がみられない時には総胆管切開口を一期的に閉鎖してよい．乙れによってT字管の挿入並びに抜去に伴なう障害をさけ，かっ入院期間を短縮する ζとができる．一般に，可能なる限り創の一期的癒合をはかるのは外科打、の責務である．

胆石症手術における総胆管ドレナージの適応と, 胆管の一期的閉鎖について

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胆石症手術における総胆管ドレナージの適応と, 胆管の一期的閉鎖について

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