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Editor,—Sheen-Chen et al(Gut 1998;42: 708–10) have advocated the use of ductal dilatation and stenting through a T-tube tract followed by choledochoscopic stone retrieval in patients with residual postoperative hepatolithiasis and intrahepatic strictures. The total number of procedures (percutaneous duct dilatation, stent placement and choledochoscopic stone extraction) per patient ranged from four to 11 (median 8). No mention is made of the length of time, length of hospital stay or total cost from initial surgery to completion of the above procedures and ultimate stone clearance. Surprisingly, the authors have not cited their two previous papers on the technique.1 ,2 While undergoing repeated percutaneous biliary intervention, patients have the discomfort and inconvenience of external T-tubes and stoma appliances to control the invariable and distressing bile leakage around the external catheters. The strategy proposed by Sheen et al also does not provide access to the intrahepatic ducts if recurrent calculi develop later after removal of the T-tube.
In order to avoid these hazards and minimise the incidence of incomplete operative stone removal and to facilitate extraction of recurrent intrahepatic stones, we have used meticulous intra-operative techniques to clear stones and create a biliary access loop to deal with recurrent stones. Full exposure of the hepatic duct bifurcation is obtained at operation and intra-operative ultrasound, cholangiography and cholangioscopy are used to locate and map the site and extent of segmental duct stones. Accessible segmental duct strictures are widened by surgical ductoplasty and impacted stones extracted.3When peripheral segmental ducts beyond the reach of conventional operative cholangioscopy are involved, intra-operative radiological manipulation with a balloon to dilate strictures and a basket to extract recalcitrant stones is used. If substantial parenchymal atrophy has occurred, or multiple cholangitic abscesses are present, the involved segment or lobe is resected in addition to duct drainage and creation of the access loop. Usually only a left lateral segmental resection is required.
Percutaneous transjejunal biliary intervention has become an integral part of the multidisciplinary management of complex intrahepatic strictures and stones since the initial descriptions by Fang and Chou,4 Barker and Winkler5 and Hutsonet al.6 The original cutaneous stoma has been replaced by a subparietal jejunal loop.7 In 21 patients with residual or recurrent intrahepatic stones we achieved successful intrahepatic biliary access in 95 (98%) of 97 puncture attempts.8 Several technical points in the jejunal loop construction are useful to create a loop which is easy to identify and enter. The access limb should be short and straight between the hepaticojejunal anastomosis and site of subparietal fixation. The terminal 4 cm of the bowel is sutured to the peritoneum of the anterior abdominal wall and marked with a parallel row of metal clips to provide “runway lights” for radiological identification and puncture (fig1). The subparietal attachment and clear marking of the loop simplify identification and allow consistently successful percutaneous entry. In difficult cases the use of high frequency ultrasound facilitates identification of the surgical clips and the needle tip during entry into the access loop. Two additional clips on either side of the hepaticojejunostomy are useful to identify the site of the anastomosis.7
As an alternative to expensive electrohydraulic lithotripsy a vascular snare used as a cheese-cutter facilitates stone fragmentation and removal in patients with soft calculi. If stones recur, as they often do, the entire sequence described by Sheen et al needs to be repeated after operative T-tube replacement. A jejunal biliary access loop eliminates the need for prolonged external tubes and is readily available for re-usage without the need for further surgery if stones or strictures recur.