If a patient has a stone in his common bile-duct, it may promote ascending cholangitis. Untreated, this may be followed by multiple abscesses in his liver, or by septicaemia. Antibiotics are useful, but surgery may be necessary. Ideally, his common bile-duct should be explored, and any stones removed. This is difficult and needs special instruments and X-rays. If it is impractical, you may be able to save his life by decompressing his common duct and inserting a T-tube (choledochostomy). This will be easier than trying to anastomose his gall-bladder to his jejunum (choledochojejunostomy), which will be difficult because his gall-bladder is diseased, and there may be a stone in his cystic duct.

A patient with cholangitis usually has a history of gall- bladder symptoms. Typically, an attack of colic is followed the next day by fluctuating jaundice, dark urine, pale stools, nausea and vomiting, fever and rigors, and a leucocytosis. His gall- bladder and liver are tender, but his gall-bladder is not palpable.

Fig. 13-2 CHOLEDOCHOSTOMY. A, expose the patient's common bile-duct. B, insert stay sutures. C, incise his common bile- duct. D, remove stones. E, insert a catheter. F, the catheter sewn in place. G, insert a T-tube.

CHOLEDOCHOSTOMY ANTIBIOTICS. in order of preference give the patient: (1) Mezlocillin, piperacillin, or azlocillin. (2) Ampicillin with gentamicin or another aminoglycoside or a cephalosporin.

INDICATIONS. Cholangitis, as described above. If he is jaundiced, with rigors and spiking fever which fails to respond to antibiotics in 24 hours, operate. If you delay he will probably die.

PREPARATION. If he has circulatory failure, give him 2 litres of 0.9% saline rapidly. If this does not soon improve him, give him blood. If he still does not improve, operate urgently; it is his only chance. Give him 10 mg of vitamin K[,1] twice daily intramuscularly. Insert a nasogastric tube.

EQUIPMENT. Desjardin's stone forceps. A T-tube or a 14 Ch urethral catheter.

INCISION. Make an upper median or paramedian incision and follow the initial steps for a cholecystostomy, as in Section 13.3, until you have exposed his subhepatic area and found his gall-bladder, cystic-duct, and common bile-duct. The incision will have to be longer than that for a cholecystostomy, so extend that incision, cutting the muscles in line with the skin incision, parallel to his costal margin and about 3 cm below it.

Place two large moist packs under his liver to get good exposure. Place another one deep in his right subhepatic space (Morrison's pouch), to absorb any of the infected bile which will later come gushing out.

Use a small gauze swab on the end of a large curved haemostat to dissect in the triangle between his common bile- duct, his cystic duct, and his common hepatic duct. Feel for his hepatic artery; his bile-duct is the tube lying immediately to its right in the free edge of his lesser omentum. His portal vein lies behind both of them. As Fig. 13-3 shows, there is considerable anatomical variation in this region. Make sure you have found his bile-ducts before proceeding further. Palpate them to be sure none of them pulsates! Then expose 2 cm of his common duct, which will probably be dilated[md]even to 5 cm or more (A, Fig. 13-2).

If in doubt, aspirate his common duct to make sure it contains bile and not blood. Now place two 3/0 catgut stay sutures on its anterior surface about 4 mm apart (B).

With the tip of the sucker close by, make a 2 cm longitudinal incision between the stay sutures (C). Suck out all the bile and exudate, and take a swab for culture and sensitivity. Using Desjardin's stone forceps, gently remove any stones that you easily can (D). The curve on the forceps may help you[md]the stones are probably well down his common duct at its lower end, where it enters his duodenum. Don't prolong this stage of the operation if it is difficult[md]you can do much harm. If there is much ''sludge', wash out his common duct by irrigating it with plenty of saline using a plain rubber catheter and a 20 ml glass syringe.

Insert a T-tube. Failing this, insert a 14 Ch urethral catheter in his common bile-duct for about 4 cm (E), and suture it to the upper end of the incision in the duct with 3/0 chromic catgut (F). Close the opening in the duct snugly round the drainage tube with the same material.

Bring the tube out through a stab incision, leaving some slack inside, in case it is pulled on. Anchor it securely to his skin with a non-absorbable suture.

Close his abdominal wall carefully[md]his wound is likely to become infected, so don't close his skin (9.8).

POSTOPERATIVELY, connect the tube to a bedside bottle, and allow it to drain freely until his jaundice and fever subside. Refer him. If you cannot refer him, do a tube cholangiogram 7 to 10 days postoperatively using ''Hypaque' or similar aqueous contrast medium diluted one part to two parts of 0.9% saline. This will help in further management. It should show any residual stones. If you find any, try again to refer him. The stones can be removed by an expert through the T-tube tract by passing a fibre-optic endoscope into his duodenum and slitting his sphincter of Oddi, or by opening his duodenum at operation. This is very difficult surgery. Only a few patients need it.

If you see no stones, and the medium flows nicely into his duodenum, try clamping the tube. Provided that he has no pain, fever, or jaundice, remove the tube.

If you cannot do a tube cholangiogram, connect the tube to a vertical length of plastic tubing (as when measuring the CVP, A 19.2) to see what pressure builds up. It should not be higher than 8 to 10 cm of bile. If after 24 hours no higher pressure develops, try clamping the tube. Remove it after two weeks if no discomfort develops. If pressure does build up in the tube, don't remove it. He may need it for months, but try to refer him. If fever and jaundice reappear, unspigot the tube[md]he will need further surgery to remove his remaining stones.