Primary closure and accept the relatively high incidence of bile leak.
Primary closure after antegrade insertion of a stent and accept the risk of pancreatitis through manipulation of the Ampullary complex especially when it has not been sphincterotomised. Insertion of a T-Tube and accept the risk of misplacement but luxury of relatively safe duct decompression. I know there is some literature supporting primary closure. I am interested to hear others experience and tips.
I would do primary closure. There is solid data to support primary CBD closure after exploration. Bes of luck.
I would also do primary closure with cleared common bole duct and I explore the duct with cholangioscopy before closure to make sure no small stone left and the distal of common duct is no stricture
I would also recommend primary closure especially after a period of cholestasis and dilated bile duct; however in the case of very small bile duct (visualized by cholangiography) either papillotomy and stent or a T-tube would be useful to avoid bile duct stricture.....
primary closure is safe in a confirmed cleared duct. hence it is prudent to perform a choledoscopy or a good quality cholangiogram. i however have not had to explore the duct via choledoctomy except seldomly. I have successfully cleared the duct via a transcystic approcah ( radiological or choledochoscopic) in 90% of the times. Will hopefully publish it in soon.
I always do primary repair of CBD but if there are multiple small stones or distal CBD pathology, watchful observation in post operative period is essential. If there is any doubt about clearance or distal patency, ERCP+ES/stenting may be supplemented for best results.
Two studies have been published in favour of Primary cbd closure from my unit,one in world jr.surg and the other in ind jr surg and the third one is to be published soon.I am in favour of routine intraoperative choledochoscopy and primary closure with an enbd tube placement that helps not only to perform a postoperative cholangiogram but also helps in managing any small residual stones by saline flushings or using contact dissolution via preplaced enbd tube.Also chances of bile leak are less and in case of any leak ,internal drainage is already in place.
My oponion is primary closure .In liver transplantation ,we do duct-- to duct anastomosis without T-tube drainage,so if the duct was cleared from stones ,I think we can perform primary closure.
Obviously the views and opinions are based on personal experience, available expertise and type of patients treated .
Personally I use T tube in the majority of my explorations. However I need to say that most of the cases I explore are cases who failed ERCP either for impossible canulation despite repeated attempts or for failed clearance due to multiple impacted stones . In these patients you may clear the duct and attempt to ensure clearance with OTC or choledoscopy but you can never be 100% sure as stones my travel back into 2ed 3ed order ducts . Leaving a T tube permits a T Tube cholangio later n prevent strictures and leak ( especially with the presence of a residual ductal stone which may lead to increased intra ductal pressure. Last but least if there would be a residual stone the intervetional radiologist can remove trans tube or pass a wire to the enbdoscopist to help in cannulation through a rendovou procedure .
Having said this in a dilated CBD, confidently cleared a primary closure can be considered
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