Current attitudes in the management of obstructive biliary tract disease

The current attitudes of surgeons towards the management of obstructive biliary tract disease were assessed by analyzing the responses of general surgeons to a 20-item questionnaire. The responses indicate that ultrasound is the most favored initial diagnostic test for suspected choledocolithiasis. Ninety-nine per cent of the respondents always or almost always insert a T-tube following exploration of the common bile duct for stones. For patients with stone impacted at the ampulla of Vater, sphincterotomy with or without sphincteroplasty is recommended by 86 per cent of surgeons. However, differences are noted in the approach to management of malignant lesions in the biliary tract. For carcinoma of the head of the pancreas, at laparotomy, if the lesion is resectable, 59 per cent of the surgeons will perform a Whipple procedure, nine per cent a total pancreatectomy, and 28 per cent recommend bypass only. For unresectable carcinoma of the head of the pancreas, 73 per cent perform cholecystojejunostomy, and 26 per cent prefer choledocojejunostomy. In addition to the biliary bypass, only 57 per cent perform a gastric bypass routinely. The favored treatment (62%) for unresectable common bile duct tumors is an internal bypass. However, following bypass, only 45 per cent recommend further treatment with radiation and/or chemotherapy. Therefore, it appears that there is agreement on the treatment of biliary obstruction due to stones. Differences are noted, however, in the approach to the management of malignant disease.