Late complications after transduodenal sphincterotomy

Letters to the editors Routine drainage and splenic surgery To the Editors: Liu et al. (Surgery 1996;119:27-33) have presented a very authoritative review of splenic anatomy, representing a major contribution since the landmark work of Michels I in 1955. Given that successful splenic salvage is dependent on a thorough knowledge of anatomic variance, this work is an invaluable reference for the surgeon. In that light we believe one issue warrants further clarification. In the last paragraph of the discussion they state, "A subphrenic drain is routinely placed in the splenic bed. This helps in drainage of exudates and in monitoring for any possible postoperative rebleeding. The drain is removed 24 hours after operation." To our knowledge no scientific support exists for this recommendation. Drains are notoriously misleading as monitors for bleeding caused by clotting in or around the drain and partitioning from the active hemorrhage. In addition, there is a lack of evidence that blood accumulated in the left upper quadrant needs to be drained as shown by the success of nonoperative management of advanced splenic injuries. In fact, the need for routine drainage of the splenic bed was disproved by a randomized study more than a decade ago. 2 Subsequent published series of trauma patients undergoing splenectomy, partial splenectomy, and splenorrhaphy have validated this observation. 3-~ Furthermore, the concept that patients undergoing abdominal solid organ resection do not benefit from routine drainage has recently been expanded to elective liver resections including formal hepatic lobectomies and trisegmentectomies. 6 If Liu et al. have data to the contrary, we would appreciate this information. Reginald J. Franciose, MD Ernest E. Moore, MD Jon M. Burch, MD Department of Surety Denver General Hospital 777 Bannock St. Denver, CO 80204 References 1. Michels NA, editor. Blood supply and anatomy of the upper abdominal organs. Philadelphia; Lippincott, 1955:210. 2. Pachter HL, Hofstetter SR, Spencer FC. Splenorrhaphy versus splenectomy and postsplenectomy drainage: experience in 105 patients. Ann Surg 1981;194:262-9. 3. Barrett J, SheaffC, Abuabara S,Jonasson O. Splenic preservation in adults after blunt and penetrating trauma. Am J Surg 1983; 145:313-7. 4. Feliciano DV, Bitondo CG, Mattox KL, RumisekJD, Burch JM, Jordan GL. A four-year experience, with splenectomy versus splenorrhaphy. Ann Surg 1985;201:568-75. 5. Pickhardt B, Moore EE, Moore FA, McCroskey BL, Moore GE. Operative splenic salvage in adults: a decade perspective. J Trauma 1989;29:1386-91. 6. Fong Y, Brennan MF, Brown K, Heffernan N, Blumgart LH. Drainage is unnecessary after elective liver resection. AmJ Surg 1996;171:158-62.

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Late complications after transduodenal sphincterotonly To the Editors: Preoperative endoscopic retrograde cholangiography and stone extraction have become a widely accepted procedure in the treatment of common bile duct stones for patients undergoing laparoscopic cholecystectomy. The technique, however, remains controversial in the treatment of fit young patients because sphincterotomy can result in late complications such as recurrent cholangitis. Sufficient long-term results for endoscopic sphincterotomy are presently not available. We reviewed the records of 214 patients who had undergone open exploration of the common bile duct for suspected choledocholithiasis between 1970 and 1980. The data were categorized into two groups, 108 patients who had undergone transduodenal sphincterotomy and 106 padents who had undergone exploration of the common bile duct only. Long-term results (13 to 22 years; mean, 16.4 years) were available for 31 patients in each group. A comparison was drawn between the preoperative status, perioperative complications, and the postoperative course, and no substantial differences between the two groups were found from the perioperative data. The long-term results, however, showed a significantly higher rate of clinical symptoms such as jaundice and chronic abdominal pain for patients who had undergone transduodenal sphincterotomy. Ten patients (32%) who had undergone sphincterotomy and three patients (10%) who had undergone simple exploration of the common bile duct had recurrent cholangitis. Chronic pancreatitis was observed in seven patients (23%) who had undergone sphincterotomy and in three patients (10%) who had undergone exploration of the common bile duct only. We concluded that transduodenal sphincterotomy effects a significant increase in late complications. Although endoscopic sphincterotomy may be less traumatizing, it can potentially result in major long-term complications. Consequently, it should be used with restraint in young patients until concrete long-term results are available. With regard to minimal invasive surgery, the data represent a strong argument for laparoscopic cholangiography and exploration of the common bile duct. Helmut Waldner, MD Klaus K. J. Hallfeldt, MD Chirur#sche Klinik Klinikum Innenstadt Ludwig-Maximilians Universitdt Nussbaumstrasse 20 80336 Munich, Germany

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