5 0 2
R. B. CATTELL
RICHARD B. CATTELL
BELIEVE that the subject that I have been assigned "Re-
constructive Procedures of the Biliary Tract" is hardly
as important as the subjects of the other two speakers,
E71 yet, unfortunately it is a subject that needs discussion.
For example, a woman 35 years of age, married, with
four children, had suffered one attack of gallbladder colic, and investi-
gation indicated that she had gallstones. She entered a hospital expect-
ing an uneventful operation for removal of the gallbladder. According
to the surgeon the gallbladder was removed without incident. How-
ever, she developed jaundice in the postoperative period. Because
of a very serious complication she required reconstructive work on the
biliary tract. This is a surgical tragedy. How much of a problem is
the repair of strictures of the bile ducts?
As Dr. Glenn has stated, the incidence of gallbladder operations is
increasing greatly and in many clinics today, it is one of the most fre-
quent abdominal operations. Dr. Coller's Committee of the American
College of Surgeons in discussing those doing surgery today, has
pointed out that a high proportion, certainly the majority of operations
of this and other types of abdominal surgery are being done by
operators with relatively little experience. If this is the case, and it
seems likely that the situation will continue, the problem of recon-
structive procedures on the bile ducts will become an increasingly
important one. An increasing number of this type of case is appearing
for treatment with distressing frequency at a number of centers.
would like to state briefly what the problem is in our own clinic.
Ten years ago, for every 12 gallbladders operated upon in our clinic
there was one operation for stricture of the common bile duct. In
I12 patients with this condition were operated upon and in
Transcript of presentation given as part of a symposium on Surgery of the Gallbladder and Bile
Ducts of the Section on Surgery, December 18, 1956.
Bull. N. Y. Acad. Med.
RECONSTRUCTIVE SURGERY OF THE COMMON BILE DUCT
the first nine months of 1956, 94 additional operations were done for
this complication. The ratio, in these last two years, of so-called uncom-
plicated gallbladder cases to strictures was three to one-that is, one
operation for stricture to three regular gallbladder operations. Many of
these strictures go unrecognized until a severe degree of biliary cirr-
In addition, in the relatively low mortality following gallbladder
operations, which may be from
may be due to duct injury. As Dr. Walters has aptly stated, anyone,
even those with the greatest experience, may have the misfortune to
injure the duct but as experience increases the danger of injury de-
creases. This high incidence of injury to the bile ducts during a gall-
bladder operation presents a problem that is very important to the
entire medical profession and it is primarily our job as surgeons, to
take whatever steps are necessary to teach a proper type of operative
procedure in order to decrease the number of bile duct injuries that
are continually being produced.
In the little time at my disposal, I think it is important to speak, even
if I encroach somewhat upon Dr. Colp's subject, on means of preven-
tion of these strictures.
There is no simple gallbladder operation. We must have good anes-
thesia, good light, good assistants and time enough to do the procedure.
When some one boasts about doing a gallbladder in eight or ten
minutes, I am always fearful of the result. Adequate incision and,
above all, the careful dissection of the cystic artery and cystic duct
with visualization of the cystic, hepatic and common ducts are impera-
tive. I am sure Dr. Colp will discuss this at some length.
Relative to the causes of the production of stricture, there are
several points that I would like to discuss briefly. It is stated by a num-
ber of surgeons that early operation for acute cholecystitis is fairly well
accepted therapy but has resulted in a higher incidence of strictures.
That has not been true in our experience.
A second possible cause of stricture is the practice of complete
removal of the cystic duct. Dr. Coller and Dr. Cole and others have
called attention to the possible danger therefrom. Here again, based
on the site of injury of the cases that we have been called upon to treat
in recent years, we do not believe that the advocacy of complete
removal of the cystic duct has increased the incidence of common
I to 5 per cent, part of the mortality
Vol. 34, No. 8, August 1958
RECONSTRUCTIVE SURGERY OF THE COMM1ON BILE DUCT
in all of these repairs.
What happens to the patients who are submitted to these various
types of operative procedures for the repair of strictures? Approx-
imately 70 per cent have a satisfactory result after the initial operative
procedure for a period of two years or more but there is always a
possibility of recurrence of symptoms. I have had one recur after 20
years of satisfactory relief, following which the patient developed a
narrowing and recurrent common duct stones behind the point of
narrowing. Thirty per cent have unsatisfactory results and should
certainly be reoperated upon without delay, because if they are not
they will have serious effects from biliary cirrhosis, including portal
The whole problem of injuries of the bile ducts and their repair is
a most unsatisfactory one. WVe can never be sure of a satisfactory result.
These patients endure not only a great deal of incapacity and suffer
considerable pain but many of them lose their lives as the result of this
complication. We must make every effort to reduce the incidence and
continue to strive to improve the operative methods that are now
Vol. 34, No. 8, August 1958