Med Preg12010; LXIII (1-2): 99-103. Novi Sad: januar-februar.

99

STRUCNI CLANCI
PROFESSIONAL ARTICLE
Klinicki centar Vojvodine, Novi Sad Strucni clanak
Klinika za abdominalnu, endokrinu i transplantacionu hirurgiju Professional article
UDK 616.366/.367-003.7-08
DOT:10.2298/MPNS 10020991

PRIMARNA SUTURA HOLEDOHA U LECENJU HOLEDOHOLITIJAZE

PRIMARY CLOSURE OF THE COMMON BILE DUCT IN THE TREATMENT OF
CHOLEDOCHOLITHIASIS
Dejan IVANOV i Pavle MILOSEVIC
Sazetak - U hirurskirn ustanovama koje imaju mogucnost izvodenja endoskopske retrogradne holangiopankreatografije sa papilo-
tomijom lecenje nekomplikovane holedoholitijaze ne izvodi se vise hirurski. Medutirn, u ustanovama gde se endoskopska retro-
gradna holangiopankreatografija jos ne radi. lecenje holedoholitijaze .Ie i dalje u rukama hirurga, pa .ie i holedohorafija, kao vid
zavrsetka eksploracije holedoha, sa uklanjanjem konkremenata iii bez uklanjanja. .I edna od ponudenih opcija. S obzirom da se u nasoj
ustanovi holangiopankreatografija jos ne izvodi rutin ski. pokusali smo u radu da odredimo mesto primarne suture holedoha u lecenju
holedoholitijaze, te indikacije i kontraindikacije za njeno izvodenje.
Kljucne reci: Duktus holedohus + hirurgija: Holedoholitijaza: Savovi: Tehnike sivenja

Summary - Surgical institutions equipped to apply endoscopic retrograde cholangiopancreatography with papillotomy do not treat
non-complicated choledocholithiasis in a surgical way any more. However, those institutions which have not yet started to perform
cholangiopancreatography apply surgical treatment of choledocholithiasis, and therefore, choledochography is still an option to
end the exploration of choledochus with or without the concrement removal. Since cholangiopancreatography has not become a
routine treatment in our institution, we have tried to determine the role ofthe primary closure ofthe choledochus in the treatment of
choledocholithiasis as well as the indications and contraindications for its application.
Key words: Common Bile Duct + surgery; Choledocholithiasis; Sutures; Suture Techniques
Uvod Introduction
Mesto primarne suture holedoha u lecenju hole- The place of the primary suturing of choledochus
doholitijaze oduvek je predstavljalo veliku dilemu in the treatment of choledocholithiasis has always
medu hirurzima. Ni danas, u vreme velikog napretka presented a dilemma for surgeons. Nowadays, with
hirurgije, ova dilema nije resena [1-3]. U hirurskim the huge advances in technology, the dilemma has
ustanovama koje imaju mogucnost izvodenja endo- not been resolved [1-3]. Those surgical institutions
skopske retrogradne holangiopankreatografije which are equipped to perform endoscopic retro-
(ERCP) sa papilotomijom lecenje nekomplikovane grade holangiopancreatography (ERCP) with papil-
holedoholitijaze ne izvodi se vise hirurski. Medu- lotomy do not opt any longer for surgical treatment
tim, u ustanovama gde se ERCP jos ne radi lecenje of noncomplicated choledocholithiasis. However, in
holedoholitijaze je i dalje u rukama hirurga, pa je i those institutions where ERCP is not yet available,
holedohorafija, kao vid zavrsetka eksploracije hole- the treatment of choledocholithiasis remains in the
doha, sa uklanjanjem konkremenata iIi bez ukla- hands of a surgeon. Choledochoraphy, with or with-
njanja, jedna od ponudenih opcija. out the removal of concrement, is an option for the
S obzirom da se u nasoj ustanovi ERCP jos ne end of the exploration of choledochus.
izvodi rutinski, pokusacemo u radu da odredimo Seeing that ERCP is not yet a routine procedure
mesto primarne suture holedoha u lecenju holedo- in our institution we will attempt here to determine
holitijaze, te indikacije i kontraindikacije za njeno the place of the primary suturing of choledochus in
iz- vodenje, the treatment of choledocholithiasis together with
the indications and contraindications for its
Indikacije za eksploraciju holedoha performance.

Pre nego 5tO je uvedena laparoskopska holecis- Indications for exploration of choledochus
tektomija i ERCP, holedoh je eksplorisan u oko
15% svih holecistektomija i konkrementi su nadeni Prior to the introduction of laporascopic chole-
u 65% slucajeva ovih eksploracija [4]. Ucestalost cystectomy and ERCP, there had been choledochus
udruzene holedoholitijaze sa holelitijazom varira od exploration in 15% of all cholecystectomies perfor-
8% do 20%. U vecim serijama laparoskopskih med and concrement was found in 60% of those ex-

Adresa autora: Doc. dr Dejan Ivanov, Klinika za abdorninalnu, endokrinu i transplantacionu hirurgiju,
21000 Novi Sad, Hajduk Veljkova 1-7, E-mail: djnivanov@yahoo.com
 100 Ivanov D, i sar. Primarna sutura holedoha

Skracenice Abbrebiations
ERCP - endoskopska retrogradna holangiopankreatografija ERCP - endoscopic retrograde cholangiopancreatography
holecistektomija incidencija holedoholitijaz~ je plorations [4]. The frequency of choledocholithiasis
znatno niza i krece se oko 3-5% [5,6]. Ova razlika u together with cholelithiasis varies between 8% and
ucestalosti objasnjava se selekcijom pacijenata za 20%. In larger series of laporascopic cholecystec-
izvo- denje laparoskopske procedure. tomy the incidence of choledocholithiasis is signifi-
Svrha eksploracije holedoha kod holedoholiti- cantly lower and ranks at 3% to 5% [5,6]. This di-
jaze je identifikacija svih konkremenata i njihovo fference in incidence can be explained by the selec-
uklanjanje. U proslosti se indikacija za eksploraciju tion of patients who have laporascopic procedure.
holedoha donosila iskljucivo na osnovu klinickog The purpose of exploring the choledochus in
nalaza i operativnog nalaza, te je i broj negativnih choledocholithiasis is identifying all the concre-
holedohotomija bio velik. U danasnje vreme indika- ments and their removal. In the past the indication
cije za eksploraciju se postavljaju na osnovu eg- for the exploration of choledochus was based exclu-
zaktnih ispitivanja i razlikuju se od ustanove do us- sively on clinical and surgical results, which caused
tanove. Apsolutne indikacije za eksploraciju hole- a high number of negative choledochotomies.
doha, prema Blumgartu [4], jesu: 1. palpabilni kon- Nowadays the indications for the exploration are set
krementi u holedohu, 2. ikterus sa holangitisom i 3. on the basis of exact testing and they differ from in-
konkrementi videni na intraoperativnoj holangio- stitution to institution. The absolute indications for
grafiji. Palpacija holedoha je cesto zanemarena, a the exploration of choledochus, according to
ona je zapravo najpouzdanija indikacija za holedo- Bloomgart [4], are: 1. palpable concrements in
hotomiju, sa tacnoscu od 98%. Opstruktivni ..ikteru~ choledochus 2. icterus with cholangitis and 3. con-
sa povisenom telesnom temperaturom pacijenta I crements seen at the intraoperative cholagiography.
drhtavicom ukazuje iii na holangitis iii na akutni The palpation of choledocus is frequently neglected
holecistitis [7]. Ako iskljucimo pacijente sa akutnim even though it is the most reliable indication for
holecistitisom, ovaj trijas znakova ukazuje na hole- choledochotomy and is 98% accurate. Obstructive
doholitijazu u 97% slucajeva. Kod aniktericnih icterus, high fever and shivering all point to either
pacijenata, intraoperativna holangiografija, zajedno cholangitis or acute cholecystitis [7]. If we discount
sa palpacijom holedoha, predstavlja najvazniju me- the patients with the acute cholecystitis the three
todu u dokazivanju holedoholitijaze i trebalo bi je symptoms point towards choledocholithiasis in 97%
primenjivati kod svih otvorenih holecistektomija of cases. In anicteric patients the interoperative cho-
[8]. Ako se tehnicki pravilno izvede, ova metoda langiography, in combination with the palpation of
ima incidenciju laznopozitivnih pregleda od 4%.. a choledochus, is the most important method in prov-
laznonegativnih od 0,2%. Prema tome, eksploraciju ing the existence of choledocholithiasis and should
holedoha treba preduzeti sarno kada je nalaz in- be applied in all open cholecystectomies [8]. If per-
traoperativne holangiografije nedvosmisleno poziti- formed technically correctly, this method has an in-
van iii kada se konkrementi palpiraju u holedohu. cidence of 4% false positive results and 0.2% false
Girard [9] u svom radu 0 otvorenim holecistek- negative results. Therefore the exploration of chole-
tomijama i udruzenim eksploracjjama holedoha dochus should be done only in cases when the re-
iznosi podatak da je kod T-drenaza, kod kojih je sults of the intraoperative holangiography are
uradena kontrolna holangiografija po plasiranju T- clearly positive or when the concrements have been
drena, a kojih je u njegovoj seriji bilo 906, sarno u palpated in choledochus. . ..
26 slucaja (2,9%) otkrivena rest kalkuloza, sto In his paper on open cholecystectomies and joint
ostavlja mesta razmisljanju 0 primarnoj suturi hole- exploration of choledochus Gerard [9] has stated
doh a posle eksploracije. U istom ispitivanju mor- that of 906 cases he had, only in 26 cases (2.9%) T
talitet u grupi pacijenata sa eksploracijom holedoha drainage resulted in rest calculosis, which leaves
bio je 1,6%, a bez eksploracije 9,3:0,s.~o ukazuje na space to consider primary suturing of choledochus
vaznost postavljanja pravilnih indikacija za eksplo- following the exploration. In the same study the
raciju. . mortal ity rate of the patients, who had h~d explora-
Jedini pouzdani metodi kojim. se l?<?~vrduje kom- tion of the choledochus, was 1.65% while WIthout
pletno uklanjanje konkremenata IZ bilijarnog stabla the exploration it was 0.3%, which means that it is
tokom operacije jesu holedohoskopija i holedoho- essential to set the right indications for the explo-
grafija posle eksploracije. Kontrolna ~olan~lOgra­ ration.
fija moze biti uradena kroz duktus cistikus I posle The only reliable methods which confirm that all
holedohorafije. Kontrolna holangiografija se ne radi the concrements have been removed from the
sarno zato da bi se otkrilo postojanje rest kalkuloze biliary tract during the operation are choledoscopy
vee i da bi se otkrila eventualna lezija bilijarnog and choledochography after the exploration. The
stabla tokom eksploracije. control cholangiography can be performed through
the ductus cysticus even after choledochoraphy. The
control cholangiography is not performed solely to
determine the existence of rest calculosis but also to
 Med Pregl 2010; LXIII (1-2): 99-103. Novi Sad: januar-februar. 101

Hirurska tehnika kod eksploracije holedoha detect possible lesions of the biliary tract from the
exploration.
Hirurska tehnika kojom se obavlja holecistek-
tomija sa eksploracijom holedoha mora biti potpuno Surgical technique in exploration
atraumatska i predstavlja osnovni preduslov za of choledocus
donosenje odluke za primarnu suturu holedoha.
Identifikacija anatomskih struktura veoma je vazna The surgical technique for cholecystectomy with
u bilijarnoj hirurgiji zbog brojnih varijacija zucnih the exploration of choledochus must not be trau-
puteva i krvnih sudova koje se javljaju kod 15-35% matic and is the basis for making the decision
osoba [7]. Nepoznavanje ovog podatka moze whether to do primary suturing of choledocus. The
dovesti hirurga u situaciju da povredi zucni vod, identification of anatomical structures is very im-
kada se operacija ne sme zavrsiti primarnom su- portant in biliary surgery because of the numerous
turom zucnog voda. Preterana disekcija hepatiko- variations of biliary canaliculi and blood vessels,
holedoha, njegovo ogoljavanje u duzini preko 2 cm which occur in 15-35% of people [7]. Poor knowl-
veoma je opasno zbog ostecenja njegove vaskulari- edge of this can cause the surgeon to damage the
zacije i posledicnog razvoja stenoze, bez obzira da li bile duct when the operation must not end in pri-
se izvodi primarna holedohorafija iIi postavlja T- mary suturing of the same. Overdissection of hepati-
dren. Instrumetalna eksploracija holedoha mora biti cocholedochus when it is laid bare over 2 ern in
nezna i precizna. Hvatanje zida holedoha hvatali- length, is very dangerous because of the possibility
com, pokusaj plasiranja sondi kroz papilu pod of damage to its vascularisation and the develop-
pritiskom jacim od dozvoljenog, guranje instru- ment of stenosis in cases of either primary choledo-
menata pod pogresnirn uglom mogu ozbiljno ostetiti choraphy or placement of T-drain. The instrumental
bilijarno stablo i onemoguciti primarnu suturu hole- exploration of choledochus must be gentle and pre-
doha[lO]. cise. An attempt at placing the probe through the pa-
piIla while applying the pressure greater than the
Primarna sutura holedoha iii T-drenaza pressure allowed or inserting the instrument at the
wrong angle can lead to serious damage of the
Zasigurno, odgovor na ovo pitanje ne moze biti biliary tract and thus make primary suturing of
jedan i jednostavan. Na odluku uticu brojni faktori choledochus impossible [10].
koje mozemo, iz didaktickih razloga, podeliti u
nekoliko podgrupa. Primary suturing of choledocus or T-drain
Postavljanje T-drena u holedoh posle njegove
eksploracije prvi put je izveo 1899. godine Kehr te The answer to this question clearly cannot be a
danas drenaza holedoha pomocu T-drena nosi nje- simple one. The decision is affected by various fac-
govo ime. Ovaj dren predstavlja veliku sigurnost u tors which can be divided into a few groups for di-
bilijarnoj hirurgiji. Prednosti njegovog plasiranja su dactic purposes.
brojne. Obezbeduje simultanu spoljasnju i unutras- In his paper on open cholecystectomies and joint
nju drenazu zuci, smanjujuci pritisak u bilijarnom exploration of choledochus Gerard [9] states that of
stablu, a ipak omogucava da dovoljna kolicina zuci 906 cases he had had, only in 26 cases (2.9%) T-
prode do creva. Smanjenje pritiska je od velike drainage resulted in rest calculosis, which leaves
vaznosti kada ocekujerno edem Odijevog sfinktera, space to consider primary suturing of choledochus
odnosno edem na papili Vateri. Postavljanje T- following the exploration. In the same study morta-
drena obligatno je kod purulentnog holangitisa zbog lity rate of the patients who had had exploration of
drenaze gnojnog sadrzaja iIi kod nalaza mulja u the choledochus had been 1.65% while without the
holedohu. Velika je prednost prisustva T-dreha u exploration it had been 0.3%, which means that it is
holedohu kada se u postoperativnom periodu otkrije essential to set the right indications for the
rest kalkuloza, jer su mogucnosti za njeno uspesno exploration.
resavanje vece. Medutim, rutinskom intraoperativ- The placement of the Tvdrain into choledochus
nom primenom holangiografije i primenom holedo- following its exploration was done for the first time
hoskopije ucestalost rest kalkuloze se znatno sma- in 1899 by Kehr and today that procedure has his
njila. I ne sarno to. Tvdrenaza ima i svoje komplika- name. This drain represents safety in biliary sur-
cije, opisane u velikim serijama pacijenata [11,12]. gery. The advantages of its placement are numerous.
Komplikacije kod izvodenja ~ -drenaza mogu se It makes both internal and external bile drainage
javiti tokom njegovog postavljanja, mtraoperatlv~o, possible at the same time thus reducing the pressure
kod njegovog odstranjenja 1 u kasnornpostoperativ- in the biliary tract but at the same time enabling suf-
nom periodu. Ako se tokom postavljanja T-dr.~n~ ficient bile to reach the stomach. It is very important
ostave duzi kraci, oni mogu ops~rUlsatl hepaticni to reduce the pressure when we can expect edema of
vod distalni holedoh iii samu papilu, te dovesti do the Oddie's sphincter or of the papilla Vateri. The
ra;;oja pankreatitisa. T-dren se moze knikovati u placement of T-drain is obligatory at purulent cho-
samom holedohu iIi na svom putu ka prednjem langitis so that the pus can be drained away or when
there is bile dust in choledochus. T-drain is essential
 102 Ivanov D, i sar. Primarna sutura holedoha

trbusnom zidu. On moze biti postavljen u lazni ka- if we discover rest calculosis in postoperative recov-
nal umesto u holedoh [7,13]. ery as with it the chances of dealing with it are bet-
Komplikacije se mogu javiti i prilikom vadenja ter. However, the incidence of rest calculosis has
T-drena, ako je on prosiven kod zatvara~ja holedo- dramatically fallen with the routine application of
hotomije, kada se otkine deo T -~rena 1 ostane u v intraoperative cholangiography and choledoscopy.
samom zucnom vodu. Po vadenju T-drena moze Not only that, T-drainage has its complications de-
nastati spoljna zucna fistula, bilom iIi bilijarni peri- scribed in large series of patients [11,12].
tonitis, koji ponekad mogu zahtevati i reoperaciju. Complications with T-drainage can occur when
Razlozi ovih komplikacija leze u neprepoznatoj dis- placing the drain, during the operation, when remov-
talnoj opstrukciji ili nestvaranju kanala oko T- ing the drain as well as in the later postoperative pe-
drena. Od poznih komplikacija svakako najznaca- riod. If the I ines of the T-drain are longer during the
jnija je stenoza holedoha, koja se javlja na mestu placement, they could obstruct the hepatic conduit,
gde je bio T-dren. distal choledochus or the papilla itself and lead to
Sve ovo nas navodi da razmislimo i 0 mestu pri- the development of pancreatitis. T-drain can be bent
marne suture holedoha u danasnje vreme. No, pos- in choledochus itself or on its way to the abdominal
tavlja se pitanje: zasto primarna sutura holedoha? wall. It can be placed in the false duct instead of the
Prednosti koje se imaju izvodenjem primarne suture choledochus [7,13].
holedoha su brojne. Izbegavaju se komplikacije koje Complications could occur while removing the
se javljaju kod T-drenaze, Nema gubitka zuci sa drain if it was sutured while closing the choledo-
hidroelektrolitskim disbalansom. HospitaIizacija pa- chotomy. Once torn, a part of T-drain may remain in
cijenataje kraca, a njihov kvalitet zivota bolji. the bile duct. On removing the drain there could
Naravno, da bi se izvela primarna sutura hole- arise an external bile fistula, biloma or biliary peri-
doha, moraju biti ispunjeni odredeni uslovi. Mora se tonitis, which can require a new operation. The rea-
izvesti kompletno uklanjanje konkremenata iz bili- sons for these complications lie in the unrecognized
jarnog stabla, mora se iskljuciti postojanje drugog distal obstruction or the failure to form a duct round
patoloskog procesa na bilijarnom stablu, na papili the T-drain. Of the late complicatons the most sig-
Vateri i glavi pankreasa, i mora se uraditi kompletna nificant one is the stenosis of the choledochus aris-
eksploracija intraoperativnom holangiografijom, ul- ing in the spot where the drain used to be.
trasonografijom iii holedohoskopijom. For all these reasons we are right to consider the
To dalje znaci da se holedohotomija moze pri- place of the primary suturing of choledochus today.
marno zatvoriti ako nije bilo promena na zidu The question is why we should perform it. The ad-
zucnog voda, nije bilo holangitisa, ako su konkre- vantages of this procedure are numerous. The com-
menti lako odstranjeni i ako je hirurg siguran da plications related to T-drain are avoided. There is no
nema zaostalih konkremenata. loss of bile nor hydroelectrolitic disbalance. Hospi-
Sve ovo nas navodi da definisemo indikacije za talisation of patients is shorter and the quality of
primarnu holedohorafiju u lecenju holedohoIitijaze: their life better.
1. negativna eksploracija, Naturally, before we perform primary suturing of
2. svi konkrementi su uklonjeni kod nekompli- choledochus there need to be certain conditions
kovane holedoholitijaze, filled. Concrement must be removed entirely from
3. negativna holedohoskopija. the biliary tract. Any other possible pathological
Kontraindikacije za primarno zatvaranje hole- process on the biliary conduit, on papilla Vateri and
doha moraju biti jasno definisane i stroge. Traumat- on the pancreatic head must be excluded. Finally, a
ske lezije zida zucnog voda tokom eksploracije complete exploration through intraoperative cholan-
bilijarnog stabla ne smeju se zavrsiti holedohorafi- giography, ultrasonography and choledoscopy must
jom bez protekcije T-drenom. Postojanje akutnog be performed.
pankreatitisa i akutnog holangitisa su apsolutne It further means that choledochotomy can be pri-
kontraindikacije. Akutni holecistitis, mehanizmom marily closed if there have been no changes in the
svog nastanka i cinjcnicom da zuc u bilijarnom wall of the biliary tract, no cholangitis and if concre-
stablu nije sterilna, ne predstavlja kontraindikaciju ments were easily removed and the surgeon is cer-
za izvodenje primarne suture holedoha. Multipla tain that no concrements have remained behind.
kalkuloza predstavlja apsolutnu kontraindikaciju All of this leads us to define indications for pri-
jedino u slucaju postojanja intrahepaticne litijaze. mary choledochoraphy in treatment of choledo-
Kod inklavacije konkrementa prepapilarno, kada cholithiasis:
soperacija se ne sme zavrsiti holedohorafijom. Kada 1. negative exploration,
je holedoh jako uskog lumena i tankog zida, postoji 2. all the concrements have been removed in case
velika mogucnost nastanka stenoze, te se izbegava of simple choledocholithiasis,
primarna sutura holedoha. 3. negative choledochoscopy.
Contraindications for the primary closure of
choledochus must be strict and clearly defined.
Traumatic lesions of the wall of the common bile
duct during the exploration of the biliary tract must
 Med Preg12010; LXIII (1-2): 99-103. Novi Sad: januar-februar. 103

Zakljucak not end in choledochoraphy without the protection

of aT-drain. Existence of acute pancreatitis and
Iz svega navedenog mozemo da zakljucimo da uz acute cholangitis are absolutely contraindicated.
dobru selekciju pacijenata, pravilno postavljene in- Acute cholecystitis does not represent contraindica-
dikacije, a u odsustvu svih savremenih tehnicko- tion to perform primary suturing of choledochus be-
tehnoloskih mogucnosti, primarna sutura holedoha cause of how it comes about and because of the fact
mora imati svoje mesto u bilijarnoj hirurgiji u that bile in biliary tract is not sterile. Multiple cal-
lecenju holedoholitijaze. culosis is contraindicated only if there is intrahe-
patic lithiasis. When there is enclavation of con-
crement prepapillory, when transduodenal approach
to papilla Vateri is applied, the operation must not
end in choledochoraphy. If choledochus has narrow
lumen and thin wall, there is a high chance of devel-
oping stenosis so primary suturing of choledochus is
avoided.

Conclusion
From the above we can conclude that primary su-
turing of choledochus must have its place in biliary
surgery and treatment of choledocholithiasis if there
are careful selection of patients, correct indications
and if there are no modern technological
possibilities.
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