Controversies in biliary drainage for choledocholithiasis and cholangiohepatitis in Singapore

Although fulminating primary cholangitis appears to be less frequently seen in recent years in Singapore, choledocholithiasis continues to be frequently encountered. A proportion of these patients probably represents the less severe forms of primary cholangiohepatitis with primary ductal calculi. These calculi are related to stasis within the bile ducts and an internal biliary drainage procedure appears logical and should be performed. There is a place for each of the drainage procedures, choledochojejunostomy, choledocho-duodenostomy and sphincteroplasty in the treatment of primary duct calculi and cholangiohepatitis. Choledochoduodenostomy is simple, safe and particularly suitable for elderly and poor risk patients and in emergency situations. Sphincteroplasty has the advantage of dependent drainage, permits removal of impacted calculi and may be suitable when the common bile duct is not grossly dilated. Clearer understanding of the pathogenesis of biliary calculi and primary cholangiohepatitis is important to foster a more logical approach in the treatment of the disease.