Importance of surgical technique in prevention of retained and recurrent bile duct stones

Abstract

Approximately 10% of the 500,000 patients who undergo cholecystectomy for gallstones each year in the U.S.A. have associated choledocholithiasis. Of the patients who have a choledocholithotomy, 10-13% are found to have retained bile duct stones in the immediate postoperative period, and an unknown additional number are found to have biliary calculi subsequently. Residual bile duct calculi come from 3 sources, namely, "retained" stones that were overlooked during the initial operation, "retained" stones that were recognized but could not be removed at the initial operation, and "recurrent" stones that re-form in the bile ducts in association with highly lithogenic bile. Most retained stones can be prevented by knowing when and how to perform common bile duct exploration. Absolute indications, which have a high yield of calculi, are: (a) palpable stones, (b) obstructive jaundice with cholangitis, (c) demonstration of stones by cholangiography, and (d) dilatation of the common duct beyond a diameter of 12 mm. Relative indications, use of which requires judgment because of a generally low yield of calculi, are: (a) jaundice without cholangitis, (b) biliary-enteric fistula, (c) small stones in the gallbladder, (d) a single-faceted gallbladder stone, and (e) pancreatitis.Technical aspects of common duct exploration that are important for prevention of retained bile duct calculi include: (a) routine use of a Kocher maneuver, (b) routine precxploratory operative cholangiography, (c) use of the balloon-tipped catheter, (d) routine completion cholangiography through a T tube, and (e) operative biliary endoscopy. A large number of retained stones results from inadequate operative cholangiography due to poor radiographic equipment, inattention to details of technique, and insufficient collaboration between radiologist and surgeon.

A 10 year single centre experience of percutaneous and endoscopic extraction of bile duct stones with T tube in situ.

“…Thus, 33-8% of patients underwent more than one attempt at percutaneous extraction, giving an average of 1-5 attempts per patient. Failed clearance was caused by stone fragmentation (8), multiple or small stones (7), impacted stone (6), stone below a biliary stricture (3), large stone (1), intrahepatic stone (1), loss of the tract (5), tortuous tract (4), a narrow tract (3), anterior tract (2), tract perforation (2), and angulated bile duct (1) and was not determined in three patients.…”

“…Thus, endoscopic duct clearance was attempted on more than one occasion in 22% of patients, averaging 1-3 attempts per patient. Failed duct clearance was the result of failure of endoscopic sphincterotomy in two patients (duodenal diverticulum (1) and papillary oedema (1)), impaction of a stone within the ampulla, intrahepatic biliary tree, common hepatic duct or cystic duct (6), stone above a bile duct stricture (3), and the T tube interfering with stone extraction (2). A stone was not found in the biliary tree in one patient and the reason for failed duct clearance was not determined in two.…”

“…The incidence of bile duct calculi in patients undergoing cholecystectomy ranges from 7-15%, and the incidence of retained common bile duct stones after positive bile duct exploration from 10-13%. 2 The incidence of retained stones after bile duct exploration may be reduced to 2% by intraoperative choledochoscopy.3 Reexploration carries a postoperative mortality varying from 3 to 28%,>9 and without choledochoduodenostomy a 21% incidence of further operation. "I Non-surgical methods of bile duct clearance in the early postoperative period are: flushing of the T tube with solvents, percutaneous extraction with specially designed steerable catheters and baskets via the T tube tract, postoperative percutaneous choledochoscopy via the T tube sinus tract, and endoscopic sphincterotomy.…”

Treatment of retained common bile duct stones: A prospective controlled study comparing monooctanoin and heparin

“…Despite duct exploration for common bile duct stones, retained stones are later demonstrated in 2-10% of patients [1][2][3]. In these patients, reoperation is associated with significant mortality and morbidity [4], and therefore several nonoperative procedures to remove these stones have been proposed as alternative methods to surgery.…”

Intraoperative Manometry – A Useful Tool in Biliary Surgery?

“…ERCP included, have been used in pre operative exploration of the patient, a reli able technique is needed for further reduction of that rate [6,14,15,17,20,[22][23][24], Several methods are in use for intraopera tive investigation of the bile ducts. Besides cholangiography, one of these is manometry to study pressure and flow conditions in the bile system.…”