Bile Duct Exploration - Types, Symptoms, Procedure, and Complications

Introduction:

Bile duct exploration is an accepted treatment method for choledocholithiasis. Choledocholithiasis is a condition characterized by the presence of gallstones in the common bile duct. Gallstones are usually found in the gall bladder, a pear-shaped organ below the liver on the right side of the abdomen. It is estimated that about 15 percent of people with gallstones have it in the common bile duct. Common bile duct stones have multiple treatment options, including endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy or bile duct exploration with cholecystectomy.

What Are Common Bile Duct Stones?

Common bile duct stones are gallstones that move out of the gallbladder and are stuck in the common bile duct. Stones can form in bile, especially for those who eat a diet rich in fat.

The bile ducts are a network of thin tubes that connects the liver to the small intestine. Its main function is to allow the bile to move from the liver and gallbladder to the small intestine. In the small intestine, bile helps digest fats in the food. Common bile duct stones can be treated by either laparoscopic, open, endoscopic, or percutaneous surgeries. This article discusses open and laparoscopic approaches.

What Are the Signs and Symptoms of Common Bile Duct Stones?

The signs and symptoms of common bile duct stones:

• Severe pain in the abdomen.

• Nausea.

• Vomiting.

• Fever.

• Yellowish discoloration of the skin and sclera of the eye (jaundice).

What Is Bile Duct Exploration?

Bile duct exploration is a procedure performed to check if anything is blocking the bile duct and restricting bile flow from the liver to the small intestine. If bile ducts are blocked, bile can backflow into the liver. This may cause jaundice or infection of the bile duct if left untreated. The main reason for bile duct obstruction is common bile duct stones. During bile duct exploration, these stones are also retrieved using different approaches. Bile duct exploration is often done with cholecystectomy (a procedure for the removal of the gall bladder). However, common bile duct stones are mainly found in patients after cholecystectomy.

What Are the Types of Bile Duct Exploration?

Open bile duct exploration.Laparoscopic bile duct exploration.

• Laparoscopic transcystic exploration.

• Laparoscopic choldochotomy.

Laparoscopic common bile duct exploration is a potential method for managing common bile duct stones at the same time as laparoscopic cholecystectomy.

How Is Bile Duct Exploration Performed?

The procedure is performed under general anesthesia. Before the procedure, the patient is advised to eat lightly. He should not eat or drink anything after midnight, and on the morning before the procedure, he should take the given medicines.

1. Open Bile Duct Exploration - An incision is made to adequately expose the cystic and common bile duct. After it is done, gallbladder removal is performed. Then, a vertical incision is made on the common bile duct. Using a five mm choledochoscope (small endoscope or thin, flexible tube that can be passed into the common bile duct) and dormia basket (a tiny instrument having four wires that can be advanced through the choledochoscope into the body to trap a stone), common bile duct stones are removed under vision.

2. Laparoscopic Bile Duct Exploration - Four small incisions are made to be utilized as ports. Laparoscopically bile duct exploration can be performed using two approaches: transcystic and trans choledochal. The trans choledochal approach is used when transcystic exploration has failed.

• Transcystic Approach - It is the default method of bile duct exploration. It is performed using a basket either by direct visualization or under fluoroscopy (an imaging technique used to get continuous real-time X-ray images on a monitor). For the direct visualization method, a 2.8-millimeter choledochoscope is used to locate the common bile duct stones. Then stone retrieval basket is placed through the working port and used to remove the stones. Once the basket has captured the stones, both the basket and choledochoscope are removed. When using fluoroscopic guidance, the basket kit used is pushed distally towards the duodenum to remove the stones. The process is repeated until all the stones are removed.

• Transcholedochal Approach - During this approach, a longitudinal incision is made on the supraduodenal common bile duct after exposure. A 5-millimeter choledochoscope and basket are used to remove the common bile duct stones. After this step is performed, the doctor prefers to perform biliary drainage or primary closure. Biliary drainage is done using either a T-tube or an endo-biliary stent. Primary closure is done with interrupted sutures using polyglactin.

3. Postoperative Care - A cholangiogram (an X-ray of bile ducts and gall bladder) is usually performed on the fifth to seventh postoperative day if a T-tube is placed. The tube will be removed after four to six weeks when the tract to the skin is epithelialized. The stent will also be removed after four to six weeks. When the transcystic approach is used, no extra care is needed other than routine postoperative care. The patient should rush to the doctor after the procedure if they experience increased pain in the abdomen, soreness, redness or drainage around the surgical site, and fever.

What Are the Complications of Bile Duct Exploration?

• Bile duct leaks can happen. A small tear or hole anywhere in the bile ducts can cause bile leakage into the abdominal cavity.

• Bile duct strictures can be experienced. The bile duct strictures occur when the bile duct gets smaller and narrower. This can occur due to an injury caused to the bile duct during bile duct exploration.

• Acute pancreatitis is an inflammation of a long flat gland called the pancreas that lies behind the lower part of the stomach. Pancreatitis can occur due to prolonged manipulation of bile ducts. The risk of acute pancreatitis is moderate.

• Bleeding, pain, and infection at the surgical site.

• Complications from general anesthesia.

• Swelling or scarring of the bile duct.

• Persistent stones (impacted or retained stones).

• Development of hernia (near one of the cuts).

Conclusion

Bile duct exploration is generally done to examine the cause of the bile duct obstruction. It helps in reducing the symptoms and preventing further complications. This procedure is often performed with surgery involving the removal of the gall bladder. Bile duct exploration is generally considered a safe procedure, although it does have a few complications that can be managed.