A Comparative Study of Choledochoduodenostomy Versus Open Choledochotomy With T Tube Placement in a Hospital Lacking Endoscopic Retrograde Cholangiopancreatography

Background: Choledocholithiasis, or stones in the common bile duct (CBD), has two types: primary stones that form in the CBD and secondary stones that migrate from the gallbladder. Management includes endoscopic, laparoscopic, and open surgical methods. In India, the availability of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery is limited often necessitating open procedures. Commonly, open choledochotomy followed by T tube placement was performed. However, postoperative management/management of retained stones can be challenging, requiring referrals for ERCP or revision surgery. This study aims to compare the outcomes of choledochoduodenostomy versus the T tube approach in a hospital setup where ERCP is either unavailable or cumbersome.

Materials and methods: This was a retrospective comparative study carried out at Rajendra Institute of Medical Sciences (RIMS), Ranchi, Jharkhand, India. The study was approved by the Institutional Ethics Committee of RIMS, Ranchi. A total of 62 patients who underwent operations for choledocholithiasis (CBD dilation ≥ 1.2 cm) from January 2023 to January 2024 in the Department of General Surgery of RIMS, Ranchi, were analyzed.

Results: The mean age group was 52 years ± 11.5 years, and two-thirds were females with a male-to-female ratio of 1:1.8. The most common presentation was biliary colic (87 %), followed by jaundice (45%). Around three-fourths of them had multiple calculi (n = 46). A total of 36 patients underwent T tube (58.1%) and 26 underwent choledochodudoenostomy (41.9 %). The mean operating time was higher for the T tube approach but not statistically significant. The hospital stay for the patients was significantly higher for the T tube approach with a p-value of <0.001. The mean T tube in situ duration was 17.60 days ± 1.2 days. On performing a T tube cholangiogram postoperatively, it was observed around one-fourth of them had T tube filling defect (n = 8), signifying the residual stone presence and referral to higher center due to unavailability of ERCP. The incidence of wound infection was significantly high among the patient who underwent T tube with a p-value of 0.017, and postoperative bile leak was significantly high among the patient who underwent T tube with a p-value of 0.047.

Conclusion: Based on our retrospective analysis, we suggest choledochoduodenostomy was safer and more efficient in aspects of lesser operating time, minimal hospital stay, less or nil retained stones, lesser postoperative wound infection, bile leakage, and possessing advantages especially to elderly patients both economically and psychologically.