경십이지장괄약근절개술 및 취관삽관술

Abstract

[한글]

[영문]

Residual stones which develop after biliary tract surgery have been a very troublesome postoperative complication even though operative cholangiography and careful surgical exploration of common bile duct were employed at the time of the primary surgery.

Transduodenal sphincterotomy was first performed in 1892 by Charlse McBurney who removed a common duct stone which was impacted in the ampullary region. This technic has the reputation of being effective in the treatment of bile stasis and a post-cholecystectomy syndrome due to residual stones.

It is well known that gall stones are found more frequently in the extra-cholecystic biliary of Koreans than in Americans or +Europeans. This factmight contribute to the increased frequency of transduodenal sphinoterotomy in our series.

From 1958 through 1967, 314 surgical procedures on the biliary tract were performed for benign conditions. Among the 314 patients, in 75 transduodenal sphinoterotomy was performed. Among the 75, in 26 the pancreatic duct was cannulated to prevent post-operative acute pancreatitis.

Indications for transduodenal sphinoterotomy were:

1. Impacted stones at the ampulla Vater or in the distal common bile duct.

2. Muddy or sandy stones in the common or hepatic ducts.

3. Multiple gall bladder or common bile duct stones.

4. Stenosis or spasm of the ampulla Vater.

5. The post-cholecystectomy syndrome.

6. Retrograde exploration for the common bil duct via the Ampulla Vater.

7. Non-calculous choleoyatitis with dilatation of the common bile duct.

The over-all complication rate after transduodenal sphinoterotomy (75 cases) was 33.3%, and among these 3 cases residual stones and 9 cases of post-operative acute pancreatitis were found. The mortality rate was 2.7%(2/75).

The fact that residual stones developed after transduodenal sphinoterotomy suggests that transduodenal sphinoterotomy terotomy is not the best nor the only method for the treatment of residual gall stones. This fact also emphasizes the need for some kind of bypass procedure such as a Roux-en-Y choledochojejunostomy.

Post-operative acute pancreatitis is a dreadful complication of transduodenal sphinoterotomy. I cannulated the pancreatic duct whenever excessive manipulation was exerted in the periampullary region during the transduodenal sphinoterotomy.

Although the incidence of this complication was 9 cases among 75 patients (12.0%), only one serious case of the 9 occurred in the group in which the pancreatic duct was cannulated.