Rr. -1. Surg. Vol. 63 (1976) 47-50
Retained common bile duct calculi W. M. CASTLEDEN* SlJMMARY
A method qf olimirrrrtiorr of grillstones remaining in thc commou bile duct crfter explorritiorr of the rliict i s clescrihed. The retained stone is flushed through the common duct sphincter into the duodenum using rripirl in/iision of’ tiormnl saline aiti n T tube. The method is quick [ind simple und is rc,commended as the first step to toke in the mnncrgement of‘ this discomfbrting group of pntienis. The method is not without potential morbidity and should only he carrictl out i i i i d w cmCfiiil-v controlic~dconditions.
GALLSTONES are common and becoming nlorecommon (Holland and Heaton, 1972). Cholecystectomy is now the most frequent abdominal operation in the United States (Galloway et at., 1973). Despite major improvements in biliary tract surgery, particularly with increasing adoption of the use of operative cholangiography, stones in the common bile duct are overlooked in 4-15 per cent of patients undergoing exploration of the common bile duct (Patterson et al., 1973). It is patients who have actually undergone choledocholithotomy who are especially at risk (Smith et al., 1957). The retained stones usually come to light at postoperative T tube cholangiography. Although some of these stones may pass spontaneously into the duodenum, approximately 80 per cent of them will give rise to obstructive jaundice, cholangitis or pancreatitis if they remain in the duct system (Hicken et at., 1954); it is therefore recornmended that retained common bile duct stones be eliminated, and this has usually implied a second operation, which has a well-reported morbidity and mortality (Larson et at., 1966; Patterson et at., 1973). Not surprisingly, over the years many papers have appeared extolling the virtues of various non-operative techniques of removal of these embarrassing stones. The earliest paper was by Walker (1891), who instilled ether into a cholecystostomy sinus to remove a cystic duct stone. Since then an increasing number of methods of removal ofthe residual stones has included :
I . Chcmictrl clis.soIirtioti ( I . Using ether (Pribrani, 1947). 0. Using ether, chloroform o r other agents (Best et at., 1953). c. Using heparin (Cardner et al., 1971). d. Using sodium cholate via the T tube (Way et at., 1972; Toouli et al., 1974).
2. Imtrumentntiori n. Extraction of the stones from the common bile duct with Mondet’s forceps via the T tube track (M;izrnriello, 1970).
17. Extraction from the common bile duct in il Dormia basket via the T tube (Mahorner and Bean, 1971 ; Margarey, 1971). c . Suction of stones from the common bile duct with a catheter passed down the T tube track (McBurney and Gardiner, I97 I ). (I. Introduction of a coude-tipped rubber catheter down the T tube track with saline irrigation under X-ray control, and/or manipulating the stone through the ampulla (Lamis et al., 1969; Galloway et 21.. 1973).
3. Other methods n. Topical lignocaine to the common bile duct (Harris and Marcus, 1946). h. Flushing with saline (Catt et at., 1974). It has also been suggested that chenodeoxycholic acid by mouth might be effective (George, 1973). I n the United States an instrument designed for the fluoroscopic removal of retained stones (Burhenne. 1973) is on the market (Medi-Tech Inc.). The multiplicity of these methods implies some dissatisfaction with them. This paper describes a very simple procedure which it is suggested should be used in the first instance.
Patients and methods Eight patients have been referred for elimination of stones retained in their bile duct after exploration of the biliary tree. In all except one case, one or more stones had been removed from the common bile duct at the initial operation, and the retained stones came to light at postoperative T tube cholangiography. Two patients had also undergone transduodenal sphincterotomy at their initial exploration. The method by which stone elimination was attempted was as follows: T-tube bile samples were sent for bacterial culture 24-48 hours before irrigation and appropriate antibiotic cover was instituted. A T tube cholangiogram was carried out on the morning of the procedure to check that the stone(s) were still present. At 0 minutes pethidine 50-- 100 mg and probanthine 30 mg were given intramuscularly. At 15 minutes 10ml of 2 per cent lignocaine were gently irrigated down the T tube. At 30-45 minutes 1000 ml of normal saline were flushed into the T tube using the standard ward intravenous giving set connected to the T tube. The patient was encouraged to move about energetically during the infusion, which was hand held at a height not exceeding 1 metre above the
W. M. Castleden Table I : SUMMARY OF RESULTS Age
and
No. of Jaundice stones removed at from CBD at Sphincteradmission first operation otomy
No. of stones o n : Postoperativc T tube cholangiogram
Final post-flush T tube cholangiogram
4 1 (proximal to T tube)
0
Case
Sex
Admission
1 2
70 M 15 F
Acute Acutc
Yes Y cs
18 3 or 4
No
3 4
42 F 34 M
Elective Acute*
No Yes
I
No Yes
I 4 or 5
0
‘At l a s t 1’
5 6 7
36 F 68 F
No
I
Yes
5
62 F
Elective Acute Acutc
Y cs
‘Sludge’
No Y cs No
I 1 2 (in diverticulum at ampulla)
8
61 M
Acute
Y cs
‘Many’
No
4
0 0 2 (still in diverticulum) 2
Yes
1
2
Postoperativc hospital stay
20 days 62 days (despite 30 days’ chenodeoxycholic acid by mouth; reoperation) 10 days 56 days (despite sodium cholate via T tube; severe diarrhoea; reoperation) 10 days 24 days 18 days 4 1 days (reouerat ion)
* This patient also had pancreatitis and polycythacmia rubra vcra. CBD = common bile duct.
N
h
Fig. 3. Crrse 5. I / , Retained stone in common bile duct. A, ATter successful flushing. U
h
Fig. I . Cusp 3 . ( I , Retained stones in common bile duct on 30 January 1973. h, Aftcr successful flushing on 2 Fcbruary.
U
b
Fig. 2 . Cow 4. a, Four or five retained stones in common bile duct. h, One o r two stones remaining after flushing.
48
T titbe exit site. The T tube cholangiogram was then repeated. The infusion was allowed to run freely throughout. In the successful ‘flushes’ the first 40-50 ml of saline ran into the T tube in a fast stream, and then all the patients developed severe epigastric or right upper quadrant abdominal pain which mimicked their presenting attacks of biliary colic. With the pain the infusion slowed down by itself to a drip o r even stopped completely for a few seconds. The pain then eased and fast saline flow, which was sometimes peristaltic, resumed. Results Flushing was successful in 4 of the 8 patients. The clinical details and results are shown in Table 1. Representative pre- and post-flush X-rays are shown in Figs. 1-4.
Retained common bile duct calculi Discussion The method described in this paper was modified from that described to the author by Professor W. Burnett of the Department of Surgery of Queensland University. In the Queensland series recently reported by Catt et al. (1974) 9 of their 10 patients grew various faecal organisms from their bile culture and 8 patients suffered post-'washout' fever. Their patients were not covered with appropriate antibiotics. All 8 patients described in the present paper had infected bile, and although antibiotics were administered, I patient (Case 8) developed symptoms of significant bacteraemia despite a serum gentamicin level of 7.4 pg/ml, and another patient (Case 1) had a rigor. It would seem that the only major danger of this procedure is cholangiovenous reflux with the development of Gram-negative septicaemia. Case 4 developed a tachycardia and showed a rise in his serum transaminase levels, suggesting an exacerbation of ascending cholangitis. I n all but 1 patient (Case 1) only one attempt was made to flush out the retained stones. Of the 4 failures, 2 patients had stones in situations inaccessible to the flushing stream. In Case 2 the retained stone was proximal to the T tube, and in Case 7 the stones were trapped in an ampullary diverticulum. In the latter patient the T tube was removed and she has remained well since. Two patients (Cases 4 and 8 ) suffered toxic effects from their washouts as described above, and it was deemed unsafe to persevere with further attempts, although in both patients 2 stones were eliminated with the single flush. Three of the 4 failures underwent operative reexploration of their bile ducts without significant operative morbidity or mortality, apart from Case 4 who developed a wound infection. The hospital stay of these patients averaged 53 days, whereas patients whose stones were eliminated by flushing were discharged after an average stay of 16 days. The flushing procedure was associated with pain in all the patients, but this is probably less than that associated with manipulation of the common duct via the T tube track. I t is certainly less than the pain associated with reoperation. Flushing can be carried out 8-10 days after the initial duct exploration and, if successful, the patient can be discharged within 36 hours. Instruments can only be passed into the common duct via the T tube track after the patient has retained the T tube as well as their stones for many weeks. Instrumentation itself is potentially dangerous to the biliary tree and requires prolonged X-ray control. Chemicals which might be irritant to the biliary tract or liver are best avoided. Should saline irrigation, as described, fail to eliminate the retained stone, the surgeon may, if he S O desires, try any other non-operative technique before embarking on reoperation. Acknowledgements The author wishes to thank Professor Burnett of the Department of Surgery, Queensland University, who first mentioned this technique. Thanks are also due to 4
Fig. 4. Case 7. Retained stones in an ampullary diverticulum which i s inaccessible to flushing.
the surgeons who referred patients for attempts at stone elimination, and also Mrs Reynolds, Research Secretary of the North Middlesex Hospital.
References and WILSON c . E. (1953) Management of remaining common duct stones by various solvents and biliary flush regimen. Arch. Surg. 67, 839-853. BURHLNNE H. J . (1973) Non-operative retained biliary tract stone extraction-a new roentgenologic technique. Am. J. Roentgenol. Radiirm Ther. Nucl. Med. 117, 388-399. CATT P. B., HOCG D. F., CLUNIE c. J . A . and HARDIE I. R . (1974) Retained biliary calculi: removal by a simple non-operative technique. Ann. Swg. 180, 247-25 1 . GALLOWAY s. J . , CASARELLA w . J. and SEAMAN w . B. (1973) The non-operative treatment of retained stones in the common bile duct. Surg. Gynecol. Obstet. 137, 55-58. GARDNER B., OSTROWITZ A. and MASUR R . (1971) Reappraisal of the possible role of heparin in solution of gallstones: a clinical extension of laboratory studies in removal of retained common duct stones. Surgery 69, 854-857. GEORGEP.(1973) Clinics in Gastroenterology: Vol. 2. No. 1. Diseases in the Biliary Tract. London, Saunders, p. 141. HARRIS F. I. and MARCUS A. s. (1946) Common duct stone relieved by injection of nubercaine solution into T-tube. J A M A 131, 29-30. BEST R . R., RASMUSSEN J . A .
49
W. M. Castleden and CALL D. w. (1954) Residual choledochal stones. Arch. Surg. 68, 643-656. HOLLAND c. and HEATON K. w. (1972) Increasing frequency of gall bladder operations in the Bristol Clinical Area. Br. Med. J. 3, 672-675. LAMIS P. A., LETTON A. n. and WILSON J. P. (1969) Retained common duct stones: a new nonoperative technique for treatment. Surgery 66, 29 1-296. LARSON R. E., HODGSON J. R. and PRlESTLEY J. T. (1966) The early and long term results of 500 consecutive explorations of the common duct. Surg. Gynecol. Obstet. 122, 144750. MCBURNEY R. P. and GARDINERH. C. (1971) Non-surgical removal of retained common duct stones: case report. Ann. Surg. 173, 298-300. MAGAREY c. J. (1971) Non-surgical removal of retained biliary calculi. Lancet 1, 10441046. MAHORNER H. and BEAN w. J. (1971) Removal of a residual stone from the common bile duct without surgery. Ann. Surg. 173, 857-863. HICKEN N. F., MCALLISTER A. J.
50
(1970) Removal of residual biliary tract calculi without re-operation. Surgery 67, 566573. PATTERSON H. C., GRICE 0. D. and BREAM C. H. (1973) Overlooked gallstones and their retrieval. Am. J . Surg. 125, 257-262. PRIBRAM B. 0.c. (1947) The method of dissolution of common duct stones remaining after operation. Surgery 22, 806-818. SMITH s. w., ENGEL c., AVERBROOK B. and LONGMIRE W. P. jun. (1957) Problems of retained and recurrent common bile duct stones. JAMA 164, 231-236. TOOULI J., JABLONSKI P. and WATTS J. MCK. (1974) Dissolution of stones in the common bile duct with bile-salt solutions. Aust. NZ J. Surg. 44, 336-340. WALKER J. w. (1891) The removal of gallstones by ether solution. Lancet. 1, 874875. WAY L. W., ADMlRAND W. H. and DUNPHY J. E. (1972) Management of choledocholithiasis. Ann. Surg. 176, 347-357. MAZZARIELLO R.
Retained common bile duct calculi W. M. CASTLEDEN* SlJMMARY
A method qf olimirrrrtiorr of grillstones remaining in thc commou bile duct crfter explorritiorr of the rliict i s clescrihed. The retained stone is flushed through the common duct sphincter into the duodenum using rripirl in/iision of’ tiormnl saline aiti n T tube. The method is quick [ind simple und is rc,commended as the first step to toke in the mnncrgement of‘ this discomfbrting group of pntienis. The method is not without potential morbidity and should only he carrictl out i i i i d w cmCfiiil-v controlic~dconditions.
GALLSTONES are common and becoming nlorecommon (Holland and Heaton, 1972). Cholecystectomy is now the most frequent abdominal operation in the United States (Galloway et at., 1973). Despite major improvements in biliary tract surgery, particularly with increasing adoption of the use of operative cholangiography, stones in the common bile duct are overlooked in 4-15 per cent of patients undergoing exploration of the common bile duct (Patterson et al., 1973). It is patients who have actually undergone choledocholithotomy who are especially at risk (Smith et al., 1957). The retained stones usually come to light at postoperative T tube cholangiography. Although some of these stones may pass spontaneously into the duodenum, approximately 80 per cent of them will give rise to obstructive jaundice, cholangitis or pancreatitis if they remain in the duct system (Hicken et at., 1954); it is therefore recornmended that retained common bile duct stones be eliminated, and this has usually implied a second operation, which has a well-reported morbidity and mortality (Larson et at., 1966; Patterson et at., 1973). Not surprisingly, over the years many papers have appeared extolling the virtues of various non-operative techniques of removal of these embarrassing stones. The earliest paper was by Walker (1891), who instilled ether into a cholecystostomy sinus to remove a cystic duct stone. Since then an increasing number of methods of removal ofthe residual stones has included :
I . Chcmictrl clis.soIirtioti ( I . Using ether (Pribrani, 1947). 0. Using ether, chloroform o r other agents (Best et at., 1953). c. Using heparin (Cardner et al., 1971). d. Using sodium cholate via the T tube (Way et at., 1972; Toouli et al., 1974).
2. Imtrumentntiori n. Extraction of the stones from the common bile duct with Mondet’s forceps via the T tube track (M;izrnriello, 1970).
17. Extraction from the common bile duct in il Dormia basket via the T tube (Mahorner and Bean, 1971 ; Margarey, 1971). c . Suction of stones from the common bile duct with a catheter passed down the T tube track (McBurney and Gardiner, I97 I ). (I. Introduction of a coude-tipped rubber catheter down the T tube track with saline irrigation under X-ray control, and/or manipulating the stone through the ampulla (Lamis et al., 1969; Galloway et 21.. 1973).
3. Other methods n. Topical lignocaine to the common bile duct (Harris and Marcus, 1946). h. Flushing with saline (Catt et at., 1974). It has also been suggested that chenodeoxycholic acid by mouth might be effective (George, 1973). I n the United States an instrument designed for the fluoroscopic removal of retained stones (Burhenne. 1973) is on the market (Medi-Tech Inc.). The multiplicity of these methods implies some dissatisfaction with them. This paper describes a very simple procedure which it is suggested should be used in the first instance.
Patients and methods Eight patients have been referred for elimination of stones retained in their bile duct after exploration of the biliary tree. In all except one case, one or more stones had been removed from the common bile duct at the initial operation, and the retained stones came to light at postoperative T tube cholangiography. Two patients had also undergone transduodenal sphincterotomy at their initial exploration. The method by which stone elimination was attempted was as follows: T-tube bile samples were sent for bacterial culture 24-48 hours before irrigation and appropriate antibiotic cover was instituted. A T tube cholangiogram was carried out on the morning of the procedure to check that the stone(s) were still present. At 0 minutes pethidine 50-- 100 mg and probanthine 30 mg were given intramuscularly. At 15 minutes 10ml of 2 per cent lignocaine were gently irrigated down the T tube. At 30-45 minutes 1000 ml of normal saline were flushed into the T tube using the standard ward intravenous giving set connected to the T tube. The patient was encouraged to move about energetically during the infusion, which was hand held at a height not exceeding 1 metre above the
W. M. Castleden Table I : SUMMARY OF RESULTS Age
and
No. of Jaundice stones removed at from CBD at Sphincteradmission first operation otomy
No. of stones o n : Postoperativc T tube cholangiogram
Final post-flush T tube cholangiogram
4 1 (proximal to T tube)
0
Case
Sex
Admission
1 2
70 M 15 F
Acute Acutc
Yes Y cs
18 3 or 4
No
3 4
42 F 34 M
Elective Acute*
No Yes
I
No Yes
I 4 or 5
0
‘At l a s t 1’
5 6 7
36 F 68 F
No
I
Yes
5
62 F
Elective Acute Acutc
Y cs
‘Sludge’
No Y cs No
I 1 2 (in diverticulum at ampulla)
8
61 M
Acute
Y cs
‘Many’
No
4
0 0 2 (still in diverticulum) 2
Yes
1
2
Postoperativc hospital stay
20 days 62 days (despite 30 days’ chenodeoxycholic acid by mouth; reoperation) 10 days 56 days (despite sodium cholate via T tube; severe diarrhoea; reoperation) 10 days 24 days 18 days 4 1 days (reouerat ion)
* This patient also had pancreatitis and polycythacmia rubra vcra. CBD = common bile duct.
N
h
Fig. 3. Crrse 5. I / , Retained stone in common bile duct. A, ATter successful flushing. U
h
Fig. I . Cusp 3 . ( I , Retained stones in common bile duct on 30 January 1973. h, Aftcr successful flushing on 2 Fcbruary.
U
b
Fig. 2 . Cow 4. a, Four or five retained stones in common bile duct. h, One o r two stones remaining after flushing.
48
T titbe exit site. The T tube cholangiogram was then repeated. The infusion was allowed to run freely throughout. In the successful ‘flushes’ the first 40-50 ml of saline ran into the T tube in a fast stream, and then all the patients developed severe epigastric or right upper quadrant abdominal pain which mimicked their presenting attacks of biliary colic. With the pain the infusion slowed down by itself to a drip o r even stopped completely for a few seconds. The pain then eased and fast saline flow, which was sometimes peristaltic, resumed. Results Flushing was successful in 4 of the 8 patients. The clinical details and results are shown in Table 1. Representative pre- and post-flush X-rays are shown in Figs. 1-4.
Retained common bile duct calculi Discussion The method described in this paper was modified from that described to the author by Professor W. Burnett of the Department of Surgery of Queensland University. In the Queensland series recently reported by Catt et al. (1974) 9 of their 10 patients grew various faecal organisms from their bile culture and 8 patients suffered post-'washout' fever. Their patients were not covered with appropriate antibiotics. All 8 patients described in the present paper had infected bile, and although antibiotics were administered, I patient (Case 8) developed symptoms of significant bacteraemia despite a serum gentamicin level of 7.4 pg/ml, and another patient (Case 1) had a rigor. It would seem that the only major danger of this procedure is cholangiovenous reflux with the development of Gram-negative septicaemia. Case 4 developed a tachycardia and showed a rise in his serum transaminase levels, suggesting an exacerbation of ascending cholangitis. I n all but 1 patient (Case 1) only one attempt was made to flush out the retained stones. Of the 4 failures, 2 patients had stones in situations inaccessible to the flushing stream. In Case 2 the retained stone was proximal to the T tube, and in Case 7 the stones were trapped in an ampullary diverticulum. In the latter patient the T tube was removed and she has remained well since. Two patients (Cases 4 and 8 ) suffered toxic effects from their washouts as described above, and it was deemed unsafe to persevere with further attempts, although in both patients 2 stones were eliminated with the single flush. Three of the 4 failures underwent operative reexploration of their bile ducts without significant operative morbidity or mortality, apart from Case 4 who developed a wound infection. The hospital stay of these patients averaged 53 days, whereas patients whose stones were eliminated by flushing were discharged after an average stay of 16 days. The flushing procedure was associated with pain in all the patients, but this is probably less than that associated with manipulation of the common duct via the T tube track. I t is certainly less than the pain associated with reoperation. Flushing can be carried out 8-10 days after the initial duct exploration and, if successful, the patient can be discharged within 36 hours. Instruments can only be passed into the common duct via the T tube track after the patient has retained the T tube as well as their stones for many weeks. Instrumentation itself is potentially dangerous to the biliary tree and requires prolonged X-ray control. Chemicals which might be irritant to the biliary tract or liver are best avoided. Should saline irrigation, as described, fail to eliminate the retained stone, the surgeon may, if he S O desires, try any other non-operative technique before embarking on reoperation. Acknowledgements The author wishes to thank Professor Burnett of the Department of Surgery, Queensland University, who first mentioned this technique. Thanks are also due to 4
Fig. 4. Case 7. Retained stones in an ampullary diverticulum which i s inaccessible to flushing.
the surgeons who referred patients for attempts at stone elimination, and also Mrs Reynolds, Research Secretary of the North Middlesex Hospital.
References and WILSON c . E. (1953) Management of remaining common duct stones by various solvents and biliary flush regimen. Arch. Surg. 67, 839-853. BURHLNNE H. J . (1973) Non-operative retained biliary tract stone extraction-a new roentgenologic technique. Am. J. Roentgenol. Radiirm Ther. Nucl. Med. 117, 388-399. CATT P. B., HOCG D. F., CLUNIE c. J . A . and HARDIE I. R . (1974) Retained biliary calculi: removal by a simple non-operative technique. Ann. Swg. 180, 247-25 1 . GALLOWAY s. J . , CASARELLA w . J. and SEAMAN w . B. (1973) The non-operative treatment of retained stones in the common bile duct. Surg. Gynecol. Obstet. 137, 55-58. GARDNER B., OSTROWITZ A. and MASUR R . (1971) Reappraisal of the possible role of heparin in solution of gallstones: a clinical extension of laboratory studies in removal of retained common duct stones. Surgery 69, 854-857. GEORGEP.(1973) Clinics in Gastroenterology: Vol. 2. No. 1. Diseases in the Biliary Tract. London, Saunders, p. 141. HARRIS F. I. and MARCUS A. s. (1946) Common duct stone relieved by injection of nubercaine solution into T-tube. J A M A 131, 29-30. BEST R . R., RASMUSSEN J . A .
49
W. M. Castleden and CALL D. w. (1954) Residual choledochal stones. Arch. Surg. 68, 643-656. HOLLAND c. and HEATON K. w. (1972) Increasing frequency of gall bladder operations in the Bristol Clinical Area. Br. Med. J. 3, 672-675. LAMIS P. A., LETTON A. n. and WILSON J. P. (1969) Retained common duct stones: a new nonoperative technique for treatment. Surgery 66, 29 1-296. LARSON R. E., HODGSON J. R. and PRlESTLEY J. T. (1966) The early and long term results of 500 consecutive explorations of the common duct. Surg. Gynecol. Obstet. 122, 144750. MCBURNEY R. P. and GARDINERH. C. (1971) Non-surgical removal of retained common duct stones: case report. Ann. Surg. 173, 298-300. MAGAREY c. J. (1971) Non-surgical removal of retained biliary calculi. Lancet 1, 10441046. MAHORNER H. and BEAN w. J. (1971) Removal of a residual stone from the common bile duct without surgery. Ann. Surg. 173, 857-863. HICKEN N. F., MCALLISTER A. J.
50
(1970) Removal of residual biliary tract calculi without re-operation. Surgery 67, 566573. PATTERSON H. C., GRICE 0. D. and BREAM C. H. (1973) Overlooked gallstones and their retrieval. Am. J . Surg. 125, 257-262. PRIBRAM B. 0.c. (1947) The method of dissolution of common duct stones remaining after operation. Surgery 22, 806-818. SMITH s. w., ENGEL c., AVERBROOK B. and LONGMIRE W. P. jun. (1957) Problems of retained and recurrent common bile duct stones. JAMA 164, 231-236. TOOULI J., JABLONSKI P. and WATTS J. MCK. (1974) Dissolution of stones in the common bile duct with bile-salt solutions. Aust. NZ J. Surg. 44, 336-340. WALKER J. w. (1891) The removal of gallstones by ether solution. Lancet. 1, 874875. WAY L. W., ADMlRAND W. H. and DUNPHY J. E. (1972) Management of choledocholithiasis. Ann. Surg. 176, 347-357. MAZZARIELLO R.
