Cholecystoenterostomy or Choledochoenterostomy for Distal Bile Duct Obstruction?
A prospective evaluation of computerized estimates of risk in the management of obstructive jaundice. Surgery, 473-6 10. A prospective, randomized clinical trial was conducted to assess the efficacy of bilioenteric bypass in noncalculous distal biliary obstruction. Thirty-one patients required bypass for either malignant obstruction or chronic pancreatitis and were randomized into two groups: cholecystoenterostomy or choledochoenterostomy with cholecystectomy [15,16]. Nine bypasses failed after cholecystoenterostomy and two after choledochoenterostomy (p <0.04). Eight of the 9 failures occurred in the subgroup of 22 patients with malignant biliary obstruction. In this subgroup, five bypasses failed within 90 days of operation, all after cholecystoenterostomy (p 0.03 compared with choledochoenterostomy). The results indicate that choledochoenterostomy is the superior operation for malignant distal biliary obstruction. Additional studies will be necessary to identify the procedure ofchoice for benign noncalculous obstructions. PAPER DISCUSSION The authors are to be congratulated for conceiving and carrying out a prospective, randomized investigation of the values and defects of cholecystoenterostomy and choledochoenterostomy as alternative bypass conduits for patients with obstructive jaundice. All too often, opinions are given about the value of a method of treatment which are not based on good statistical evidence. Futhermore, surgeons are commonly criticized for not using prospective, randomized trials. Thirty-one patients have been included in their trial, 15 undergoing cholecystenterostomy (CCE) and 16 choledochoenterostomy (CDE). Twenty-two of the patients had malignant jaundice, the remaining nine jaundice secondary to chronic pancreatitis. In the malignant group, 19 patients suffered from pancreatic carcinoma. A variety of other procedures, including gastroenterostomy, pancreaticoduodenectomy, colonic resection and gastrectomy were performed as necessary on selected patients. Patients were randomized according to whether the last digit of their social security number was odd or even. To be included in the trial, the patient needed to have evidence of a dilated common bile duct, a gallbladder and