Choledocholithiasis

is Professor of Surgery at Baylor University Medical School and Chief of Staff for the Harris County Hospital District in Houston, Texas. Dr. Jordan received his medical degree from the University of Pennsylvania and did postgraduate work at Grady Memorial Hospital, Tulane University, and the Mayo Foundation. He is a regent of the American College of Surgeons and a Consultant in Surgery for the Veteran’s Administration Medical Center.

GALLSTONES HAVE PLAGUED THE HUMAN RACE for thousands of years, but surgical intervention for relief was not introduced until the seventeenth century. Early procedures included dilatation of fistulas or simple aspiration of infected bile. Bobbs is credited with the first elective cholecystotomy and removal of stones in 1867, but the preoperative diagnosis in this patient was ovarian cyst. 26 The first successful planned cholecystectomy was performed almost exactly 100 years ago by Langenbuch in 1882; and in 1890, only eight years later, the first successful planned extraction of stones in the common duct was performed by Courvoisier. lo& 44 Although steady advances have been made in our understanding of biliary tract disease and the surgical management of choledocholithiasis since that time, this disease remains a major medical problem. Approximately 5,0008,000 deaths are attributed to gallstone disease in this country each year. In the United States, gallstones constitute one of the most frequent diseases requiring surgical intervention. D. M. Small estimates that twelve million women and four million men in the United States have gallstones at the present time, and that approximately 800,000 new cases of cholelithiasis appear each year.ls3 Gallstones are found in lo-30% of all patients over the age of 40. The incidence steadily increases in the aging population. In an autopsy study by Johnson and Sprinkle, 23% of all patients over age 60 had allstones, the incidence being highest in the eighth decade. !3f They are more common in women by a ratio of four to one, but the difference in sex inci723

dence is most marked in young people and tends to disappear with the passage of time. Appleman et al., in a study of 4,948 patients, found that the difference in sex incidence was not great above age 70.5 It is believed that in Israel, and Central American and South American countries the prevalence of gallstones is even higher than in the United States, and it is known that in the United States, the American Indians have by far the highest incidence-much greater than that of the population of European extraction. In contrast, the incidence is less than five percent in Japan, and members of the Masai tribe in East Africa apparently do not have gallstones.50 In some countries, primary formation of stones within the biliary tract is recorded with some frequency. Biliary tract disease of the Orient is often associated with special problems which are now also seen in this country from time to time. Yellin and Donovan reviewed the experience at the Los Angeles County Hospital and found 14 immigrants with a syndrome consistent with “Oriental cholangiohepatitis.” Nine had proven helminthiasis and the remaining five came from an area of endemic helminthiasis. All had biliary lithiasis.‘il In these patients, common duct stones are usually multiple, often black and friable. The general experience in the United States, however, supports the contention that virtually all stones in the common duct have passed from the gallbladder, rather than forming primarily in the duct, excluding patients with obstructin lesions such as stricture, which prevent adequate drainage.3g’ B The passage of stones into the common bile duct is well documented. In fact, total disappearance of stones from the gallbladder by passage through the duct into the intestinal tract may occur, though complete resolution of cholelithiasis by this mechanism is uncommon.114’ lsl The reported incidence of choledocholithiasis in patients having cholelithiasis varies from 8 to 16% (Table 1). 213gs83, ‘17, 185 This variation in incidence relates somewhat to patient population and, in surgical series, to the criteria used for exploration of the common bile duct. In a study of 4,948 patients reported by Appleman et al., the common duct was explored in 22.8% and stones were found in 42.6% of those in whom choledochostomy was performed, or 9.7% of the entire group. He found that although 22.8% of all patients operated upon had common duct exploration, the need for this maneuver also increased steadily witkl;Fe, being 20% at age 30 and increasing to 55% at age 80. ’ PATHOGENESIS

The major components of gallstones, whether in the gallbladder or common bile duct, are cholesterol, bile pigment and cal724

TABLE

l.-INCIDENCE

AUTHOR

Appleman, et al. Bartlett and Waddell Colcock and Liddle Hampson and Petrie Martin and van Heerden* *Martin and van chronic noncalculous

OF CHOLEDOCHOLITHIASIS

TOTAL CASES OF GALLSTONES

EXPLORATION OF COMMON BILE DUCT, PERCENT

IN PATIENTS

WITH

GALLSTONES

PATIENTS WITH STONES FOUND AT EXPLORATION OF COMMON BILE DUCT,PERCENT

OVERALL INCIDENCE OF COMMON DUCT STONES, PERCENT

4,948 2,243

23 42

43 36

10 16

1,077

36

35

12

2,090

16

48

8

16

65

11

732 Heerden reported cholecystitis.

a 22%

incidence

of common

duct

stones

in patients

cium. The majority of stones are mixed, often containing some bile pigment and some calcium as well as cholesterol. In the United States, cholesterol is the primary component; l&25% of these stones contain enough calcium to be visualized on simple roentgenographic study of the abdomen. The major invest’igations into the pathogenesis of gallstones have concentrated on abnormalities of cholesterol metabolism. It is beyond the scope of this manuscript to discuss in detail the pathogenesis of cholesterol stones. The generally accepted concept today is characterized by the observations of Small. He has plotted triangular coordinates of lecithin, the major phospholipid in bile, bile salts and cholesterol, and demonstrated that gallstones are likely to form in individuals whose cholesterol concentration is high in proportion to bile salts and lecithin, which tend to keep cholesterol in suspension.176’ ls3 Stones consisting primarily of pigment occur in individuals with hematologic disorders that cause rapid destruction of red cells and increased hepatic excretion of the breakdown products. ANATOMY The biliary ducts begin as small ductules in the substance of the liver. These join to form larger and larger ducts until the right and left main hepatic ducts are formed. These join to form the common hepatic duct, usually in the region of the capsule of the liver-sometimes just within the liver substance, sometimes just outside of the capsule. At a variable distance between the liver and the duodenum, the cystic duct joins the hepatic duct to form the common bile duct. This duct can be divided into four segments. The first segment extends from the region of the junction of the cystic and hepatic ducts to the edge of the duodenum. 725

with

The second portion is the retroduodenal portion. The duct then courses through a groove in the pancreas where it is usually referred to as the intrapancreatic portion. The fourth portion, or duodenal portion, is in the wall of the duodenum. At or near the entrance to the duodenum, the common bile duct is joined by the pancreatic duct to form the ampulla of Vater. As the duct courses from the liver to the duodenum in the hepatoduodenal ligament, the common bile duct lies to the right, or lateral to the common hepatic artery and in a plane anterior to the portal vein which normally lies posterior and somewhat between the bile duct and the hepatic artery. In general, the vein is closer to the hepatic artery than to the bile duct (Figs 1 and 2). The description just given would constitute “normal anatomy,” but the variations are many, and it has been stated that there are more anomalies in the one cubic centimeter of space surrounding the region of the cystic duct than in any other area of the body. These include anomalies of the major ductal system, of the junction of the cystic duct with the major ductal system and relations to the hepatic artery. Dowdy, in a dissection of 100 autopsy specimens found a marked variation in the length and diameter of these ducts (Table 2).52 Of particular significance is the length of the cystic duct and its junction with the hepatic ducts. Although typically it is Fig l.-Normal anatomy of the bile ducts and relationship tures. (From Dowdy G.S., Jr.: The 5iliav Tract Philadelphia:

to surrounding Lea & Febiger,

Callbladder Uuadrate lobe CysticArtery Hepalicllurl CyslieOuct

f?ltpatodundenal ligament $astroduodenalArterv Right GastricArtery

Duodenum 726

struc1969.)

:< )F

Duct _..:)” Rt.Hepatic ‘.i ..,s.,. ,:‘. .,y lt.Hepatic Duct .:. ~.i .;:.I,.’ Common Heaatic Duct iAL-.-

CvsticDuct

Eommon I haduodenal

,Y-,I)

Fig P.-Anatomy Tract Philadelphia:

of the extrahepatic bile ducts. Lea & Febiger, 1969.)

(From

Dowdy

G.S.,

Jr.: The Biliary

thought to join the common hepatic duct in the hepatoduodenal ligament at a relatively acute angle, it may enter the posterior, the anterior or even the left side of the duct. The cystic duct may course downward in a common sheath with the hepatic duct for some distance before actually entering it. Thus, the two structures may be difficult to separate and it may be dangerous to TABLE 2.-EXTERNALMEASUREMENTS OF THE BILIARY DUCTS (AUTOPSY SPECIMENS)*

I---SMALLEST Common duct Hepatic duct Left hepatic duct Right hepatic duct

1.5 0.8 0.2 . FI

Common duct Hepatic duct Right hepatic duct Left hepatic duct *From

Dowdy

0.4 0.4 0.3 0.2

LENGTH

(CM)

LARGEST 9.0 5.2 3.5 2.5 XAMETER(CM), 1.3 2.5 1.2 0.8

IAVERAGE 5.0 2.0 1.0 0.8

0.66 0.8 0.4 0.34

G. S., Jr.” 727

attempt to separate them, as such a dissection may injure the common bile duct. This anatomic arrangement may make it difficult to identify all of the stones in the ductal system. The cystic duct may also enter either the right or left hepatic duct, rather than the common hepatic duct. There are many anomalies of the hepatic ducts themselves. Dowdy, in his dissections, found that in 76% of the specimens studied there were two main hepatic ducts-the right and left. However, 18% had three hepatic ducts and 6% had more than three hepatic ducts. Furthermore, accessory ducts were found in 15% of cases; many of these are in close approximation to the cystic duct and may not be recognized if a careful dissection is not accomplished. Accessory ducts entering directly into the gallbladder are usually small, but can be quite large and may contain gallstones. Accessory ducts up to 0.4 cm in diameter have been recorded. The angle with which the right and left hepatic ducts join is also variable. In 37% of Dowdy’s specimens, the ducts joined at an acute angle instead of forming a classic Y. The left duct commonly lies in a more horizontal position than the right duct, and, as will be noted later, the left duct has a greater propensity to have intrahepatic stones than does the right. The common bile duct may be duplicated and it may enter the gastrointestinal tract in anomalous positions, including entrance of the duct into the stomach. It may be a bifurcating duct with both openings either into the stomach or duodenum or one into each, or there may be two entirely separate ducts which enter the duodenum independently. The duct may enter the duodenum independently of the pancreatic duct. Deitch recently studied the diameter of the common duct in 100 consecutive patients at operation.47 The external width of the common duct ranged from 0.5 to 1.9 cm in patients with gallbladder disease. The roentgenographic measurements of these same ducts ranged from 0.4 to 1.4 cm. The external diameter of the duct in 10 patients with disease in the common duct ranged from 0.5 to 2.6 cm and the roentgenographically measured internal width from 0.4 to 2.2 cm. A group of 35 patients with an externally measured common duct greater than 1 cm had common duct calculi, while only 2 of 65 with a common bile duct less than 1 cm had common bile duct calculi. The common bile duct is supplied by an arterial plexus which surrounds the entire duct. This network arises from multiple sources, including the gastroduodenal artery, the hepatic artery and the cystic artery. Northover and Terblanche have demonstrated that there is a difference in the blood supply in the human bile duct from that of the pig and the baboon. Much of the supply arises from the retroduodenal branch of the gastroduodenal artery. The supply from above is more tenuous.14’ Thus, 728

when the common duct is totally divided, one must ascertain that the transected portions of the common duct have an adequate blood supply if an anastomosis is to be performed. Microscopically, the lining of the duct is composed of tall columnar cells, often thrown into folds, and there are elastic fibers in the subepithelial connective tissue. The presence or absence of muscle fibers within the duct is, however, a subject of considerable dispute. There are those who have maintained that there are muscle fibers throughout the common bile duct, and thus, peristaltic waves or spasm of the duct may occur. Others, however, maintain that no one has ever visualized any contractions of the common duct in the human and, furthermore, indicate that in their studies no microscopic evidence of muscle cells has been found except in the duodenal portion near the ampulla of Vater. Debate also exists as to whether these are muscle fibers of the duct itself or whether these are extensions of duodenal muscle fibers onto the duct.lr2, lgg The distal end of the common duct or, depending upon the anatomy, the ampulla of Vater, is surrounded by muscular fibers which comprise the sphincter of Oddi. This sphincter is normally in a state of tonic contraction which maintains a low pressure within the common bile duct and is responsible for the pressure which results in filling of the gallbladder. Through the sphincter, bile empties into the duodenum throughout the day in small spurts, rather than in a steady flow. Because of the tonic contraction of this musculature, the distal end of the common duct is quite narrow as compared to the common duct above this point. Thus, it is in this area that gallstones are most likely to become lodged and result in obstruction of the ductal system. The usual description of the anatomy of the hepatic artery is a common hepatic artery which courses the hepatoduodenal ligament in roughly the same plane and to the left of the common bile duct. The branching of the artery is usually well within the hepatoduodenal ligament and the right hepatic artery passes posterior to the common hepatic duct, giving off the cystic artery in the triangle of Calot. There are many anomalies. The right hepatic artery may course anterior to the common bile duct, and therefore, must be protected during exploration. The cystic artery also may come from the main trunk of the hepatic artery and cross anteriorly to the common bile duct or the common hepatic duct. There may be multiple cystic arteries. There may be multiple right hepatic arteries. Furthermore, either the common hepatic artery or the right hepatic artery may arise from the aorta or the superior mesenteric artery, and, rather than lying in the usual position, may lie to the right or posterior to the common hepatic duct. At times it will be found between the portal vein and the vena cava. 729

PHYSIOLOGY 0ster and associates found a resting intraluminal pressure in the gallbladder, varying from 3-11 mm Hg in surgical patients and no change in intraluminal pressure was demonstrated during the measurements.146 A high pressure zone was located at the cysticocholedochal junction. The pressure in the common bile duct was uniformly higher than the pressure within the gallbladder. The mean pressure of the common bile duct was approximately 15 mm Hg and the same range, except for one low reading in a patient with gallstones, was observed in those with and without common duct stones. In all patients a high pressure zone was identified at the choledochoduodenal junction. Measurements at the sphincter of Oddi revealed pressures varying from 50-240 mm Hg. Although peristalsis in the common duct has been reported, most authors are not able to confirm this observation.l”, ’ 2, 146 Salomon and Roseman measured biliary tract resistance in 142 patients at the time of cholecystectomy.167 A metal cannula was placed into the common duct through the cystic duct stump following cholecystectomy and contrast solution was infused into the common bile duct at the rate of 10 milliliters per minute, after obtaining a zero pressure point for the equipment. Resistance was calculated in resistance units defined as pressure (mm Hg)/flow(ml/min) after two infusions of 60 seconds each. Resistance of less than 2.5 units was found in only one patient with a common bile duct abnormality and only two patients with normal common bile ducts had resistance values greater than 2.5 units. Overall, the technique accurately determined common duct abnormalities in 97.9% of the cases studied. These authors believe that the technique will aid in eliminating the failure to find common duct pathology and will decrease the need for unnecessary common duct exploration. Many drugs have an effect upon the sphincter of Oddi. Morphine, Demerol, and codeine cause contraction of the spincter of Oddi, in decreasing order of potency. This may impede the flow of bile and cause a rise in intraductal pressure. Murphy and associates found that one currently available narcotic drug, fentanyl citrate, did not result in an increased pressure in the common duct. Other agents cause relaxation of the sphincter, including nitroglycerine, other nitrates and glucagon. Recognition of these drug effects is important in the interpretation of operative cholangiography.13i CLINICAL

FEATURES

SYMPTOMS The clinical thiasis include 730

findings leading the classic triad

to suspicion of choledocholiof chills and fever, pain and

jaundice. When these are present in a patient with known cholelithiasis, the diagnosis is relatively secure. In those patients without a gallbladder, the differential diagnosis of obstructive jaundice requires more specific evaluation, because in the patient with known gallbladder disease, operation is indicated on this basis, alone; whereas, in the patient without gallbladder disease, one must exclude the possibility of other disease processes. The general clinical factors that must be considered are the patient’s age, the type of pain, the character of the jaundice, the presence or absence of weight loss, the gradation of symptoms and the presence of prior symptoms of a similar nature. Many patients have no recognized symptoms and the stones are found at the time of cholecystectomy or at autopsy.72, 75 It is rather remarkable at times to observe a common duct that is dilated and filled with stones of varying sizes, but which have never been known to cause symptoms. The symptoms, therefore, are due to complications of stones. COMPLICATIONS OF CHOLEDOCHOLITHIASIS OBsTRucTIoN.-stones may remain in the common bile duct for many years and cause no symptoms or complications. The most common complication is that of obstruction of the common bile duct, usually due to the impaction of stones in the region of the ampulla of Vater. Obstruction may lead to a variety of problems 25,109,117 Pain.-Pain due to common duct stones usually means that the stone has become impacted in the distal common duct where there are muscle fibers which may go into spasm. The pain may be very severe and may require narcotics for relief. Pain is located in the right upper quadrant and may radiate posteriorly in the same distribution as that seen with the pain of gallbladder colic. Jaundice.-Jaundice is the most common serious complication of ductal obstruction. The presence of jaundice, when due to common duct stones, usually means obstruction of the biliary tract. Jaundice in the absence of common duct disease occurs in patients with acute cholecystitis due to ascending cholangitis, but serum bilirubin concentrations as high as 5 mg %, due to gallstones, are almost always due to obstruction. Jaundice is usually fluctuating and most patients with obstructive jaundice resulting from common duct stones will have complete resolution of jaundice on expectant therapy. In some instances, the jaundice is relieved because the stone passes into the duodenum, but in most instances, the stone simply floats back up into the common duct, away from the narrow distal end, as edema subsides or as dilatation of the duct develops. This is an important concept, because one should not presume that the common duct 731

has become free of disease when jaundice clears. Rather, tient is at high risk for having further difficulty.

the pa-

Sepsis.-Infection is the most serious immediate complication of biliary tract obstruction. Symptoms of infection are chills, fever, pain and, in severe cases, septic shock. While cholangitis may occur in patients with simple cholecystitis, the incidence is highest in patients with obstruction due to choledocholithiasis.61 Wolloch and associates found that 65% of all patients undergoing elective cholecystectomy who required choledochotomy as a part of the operative procedure had positive bile cultures as compared to only 21% positive cultures in patients requiring choleare Eschcystectomy alone.210 The most common organisms erichia coli, Klebsiella and Enterococcus organisms, although many other organisms including Pyocyaneus, Staphylococcus and Salmonella have been isolated. Of particular concern is the high incidence of Salmonella organism in immigrants from countries in which such infections are frequent. In addition to the aerobic organisms listed, anaerobic organisms also are found. In a study by England and Rosenblatt, Bacteroides fragilis was the single most commonly isolated anaerobe, and this bacterium ranked fourth in frequency behind E. coli, Streptococci and Klebsiella organisms. Pseudomonas aeruginosa and Clostridium perfringens were also commonly isolated in their study.53 In this study, aerobic organisms only were found in 60% of patients, and mixed aerobes and anaerobes in 39% (Tables 3, 4). In only one percent of patients were anaerobic organisms idenTABLE

3.-AEROBIC BACTERIA ISOLATED FROM BILIARY TRACT CULTURES* ORGANISM

Escherichia coli Streptococcus, group D Klebsiella organisms Pseudomonas aeruginosa Streptococci, viridans group Enterobacter cloacae Proteus mirabilis Staphylococcus epidermidis Proteus morganii Citrobacter freundii Corynebacterium species Pseudomonas species Enterobacter aerogenes Staphylococcus aureus Citrobacter diversus Lactobacillus organisms Miscellaneous *From England D.M., Rosenblatt tPercent of 701 isolates from taken from 251 patients. 732

PERCENT? 24 19 17 8 7 3 3 3 3 2 2 1 1 1 1 1 J.E.53 cultures

TABLE

4.-ANAEROBIC BACTERIA ISOLATED FROM BILIARY TRACT CULTURES* ORGANISM

Anaerobic gram-negative Bacteroides organisms B. fragilis Fusobacterium Clostridium organisms C. perfringens Nonsporing gram-positive Anaerobic cocci

PERCENTt

bacilli

bacilli

50 45 38 5 39 32 8 3

*From England D.M., Rosenblatt J.E.53 tPercent of 157 isolates from cultures from 100 patients.

tified as the only bacteria present. Singh et al. in another study reported a 57.1% incidence of infected bile in patients with obstruction of the common bile duct, and a similar incidence of this complication has been observed by virtually all authors.l” As bile is normally sterile, the presence of significant numbers of bacteria must be considered abnormal, even though clinical manifestations are not yet present. When clinical manifestations occur, they may be mild and the infection easily controlled with antibiotic therapy. In the most severe cases, however, acute suppurative cholangitis may prove fatal. In most of the fatal cases, however, spread of the infection into the blood stream with septicemia has occurred prior to death. The development of severe septic shock is frequently seen in such patients. The bacterial flora cultured from the bloodstream parallel that described above as the commonly identified bacteria in the biliary tree. The bile is thicker and more viscous than normal, but still easily identifiable as a secretion from the liver. In the face of neglected infection, frank pyohepatosis may develop with marked dilatation of the entire ductal tree with frank pus. It is noteworthy that infection is much more common in patients having gallstones and partial biliary tract obstruction than in patients with complete obstruction due either to carcinoma or to gallstones, and the presence of infection in patients with “white bile” is unusua1.87 Dilatation of the common bile duct.--When obstruction persists for a rolonged period, dilatation of the common bile duct will 0ccur.l Y 3 The exact time required for biliary tract dilatation is not well documented, though there are some studies that have demonstrated dilatation within one week after the onset of jaundice. In general, the longer the period of obstruction, the greater the degree of dilatation of the common bile duct. As noted in the section on anatomy, the common bile duct normally is 5-7 mm in diameter and it is generally agreed that a diameter exceeding 733

0.9-1.0 cm indicates ductal obstruction. With dilatation, stones may enter secondary biliary radicles and be a factor in development of sepsis and stricture. Biliary cirrhosis.-Chronic obstruction of the biliary tract may cause permanent hepatic damage, particularly when chronic low grade infection exists. Glenn has recorded the presence of infection in liver cultures of patients with choledocholithiasis, and pointed out that the presence of infection is a significant factor in the hepatic damage that may occur from this disease.73 INTRAHEPATIC STONES.-Stones in the biliary ductal system may move to any portion of the system large enough to accommodate the calculi. Thus, while most stones are in the extrahepatic ducts, stones in the intrahepatic ducts must always be considered. Simi and associates reported intrahepatic stones in 1.3% of their patients requiring biliary tract surgery.“’ Nakayama and associates, in a large collected series, found intrahepatic calculi in 4.1%, while Sato, in a review of this subject, found incidences as high as 30%.1352 I70 The great majority of reports, however, are in the l-5% range. Intrahepatic stones, apparently, are much more common in the Orient, where primary ductal stone formation occurs frequently. In the United States, most intrahepatic stones are cholesterol stones, but in 1590 cases collected by Nakayama and associates from a nationwide survey in Japan, the majority were of the bile pigmentcalcium variety. The stones are most commonly found in the left hepatic duct. The reason for the predilection for stone formation in the left hepatic duct has not been fully delineated, but it is an almost universal finding. Important factors may be the length of the duct, and the more transverse location of the duct. Many secondary ducts lie in a dependent position. All of these findings may impair drainage. Stones that are easily removed do not constitute a special problem, and should not be considered a complication; however, those stones that cannot be removed easily may result in stricture of intrahepatic ducts and sepsis (Fig 3). COMMON DUCT STRICTURE.-Stricture of the common duct due to gallstones is a rare complication which results only from long standing neglected disease with recurrent episodes of chronic infection and resultant scarring. CHOLEDOCHOENTERIC FISTULA.-Fistulas from the common bile duct into the duodenum are relatively uncommon. The major cause is peptic ulcer. Calculous disease accounts for less than 10%. Fistulas can be suspected on the basis of pneumobilia, as biliary enteric fistulas constitute the cause of pneumobilia in over 90% of cases.137’ 145 The problems of choledochoenteric fistulas include the development of infection, stricture formation 734

Fig 3.-Cholangiogram demonstrating including stones in dependent secondary

and gallstone ileus secondary iary tract into the duodenum.

multiple stones in the and tertiary ducts.

left hepatic

ducts,

to passage of a stone from the bil-

PANCREATITIS.-In the United States, gallstone PanCreatitiS accounts for approximately 40% of all cases of pancreatitis and in over 70% of cases in women. Freund and associates report that gallstone disease is an etiologic factor in 76% of all patients developing pancreatitis in Israel, as alcoholism is rare.63 In 18 patients in whom the diagnosis was difficult in the preoperative period, gallbladder pathology was demonstrated at the time of operation. Choledochotomy was performed in only six patients with suspected common duct stones. During follow-up periods from two to eight years, there was no recurrent pancreatitis after the gallbladder was removed. These studies, as well as others, have suggested that primary gallbladder disease, in the absence of common duct pathology, may cause pancreatitis. The importance of common duct stones, however, has been a subject of study for 80 years. Acosta and associates believe that choledocholithiasis is the cause of gallstone pancreatitis.’ They reported the finding of a gallstone impacted at the ampulla of Vater in 33 of 46 patients operated upon between 6 and 40 hours after the onset of symptoms and recommended early operation in patients with gallstone pancreatitis. It was their belief that those patients in whom ductal stones were not found had, in all likelihood, already passed the stone into the duodenum. This concept has been supported by the studies of Kelly who found 735

gallstones in stools of 38 of 45 patients (84%) with gallstone pancreatitis, and in only five patients (11%) with known gallstones without pancreatitis.“l He, too, concluded that temporary occlusion of the ampulla of Vater with passage of stone was the likely cause of gallstone pancreatitis. In patients undergoing elective operation for gallstone pancreatitis, however, the incidence of common duct pathology is not significantly greater than in patients without pancreatitis. The majority of evidence in the United States fails to support the concept that common duct pathology is necessary for the production of pancreatitis in patients with gallstones. On the other hand, when operating upon patients with gallstone pancreatitis, the surgeon must ensure the absence of common duct pathology or correct any which is present if prevention of further attacks of pancreatitis is to be accomplished. Acosta’s reports would indicate that early operation will decrease the mortality rate in gallstone pancreatitis, but this is contrary to the general opinion in the United States. Welch and White in a study of patients with gallstone pancreatitis utilized “delayed operation” in the majority of patients. The term “delayed” referred to operation delayed from 2 days to 2 weeks following admission to the hospital. In this group there were five deaths, for a mortality rate of 5%. There were 25 patients who were operated upon at a later date, ranging from a minimum of 4 days after discharge to 8 years. None of these patients died. In this group of patients, choledocholithiasis was present in 27% of the patients operated on earlyiOtnd in 16% of patients operated upon a subsequent admission. In our institutions, the lowest mortality rate has been achieved with conservative initial treatment and correction of the biliary tract pathology at the time of election after the inflammatory changes in the pancreas have subsided. LABORATORY DETERMINATIONS In a patient exhibiting pain only, there may be no abnormal laboratory determinations. In the presence of sepsis, one may anticipate a significant elevation of the white blood cell count and an increase in polymorphonuclear cells in the differential count. Appropriate laboratory tests for hemolytic disease may be indicated. The most important laboratory tests in the patient who is jaundiced are those of hepatic function. These will aid in the differentiation of obstructive jaundice from prehepatic or intrahepatic jaundice. In the classic case, there is elevation of the serum bilirubin concentration and an elevation of the alkaline phosphatase value with minimal elevations of the serum transaminase values. Pellegrini et al. studied 178 patients with obstructive lesions who had elevations of the serum bilirubin or alkaline phosphatase, or both, to delineate more specifically the 736

significance of these studies in differentiating the !zge of obstructive lesion. Their findings corroborated others. The alkaline phosphatase value often increases prior to elevation of serum bilirubin concentration, but the degree of abnormality of this test is not of great predictive value. On the other hand, serum bilirubin values greater than 14 mg % are rarely caused by common duct stones alone, and clinical jaundice persisting for more than a month is uncommonly due to common duct stones. Our observations would agree with these; however, patients with common duct stones may have symptoms and laboratory values typical of malignant obstruction, and patients with malignant obstructing lesions may have clinical features and laboratory values typical of common duct stones. Fortunately, there are procedures which allow a high degree of diagnostic accuracy. Thus, when there are symptoms or laboratory findings suggesting the possibility of an obstructing lesion of the common bile duct in a patient without proven gallstones, definitive studies should be undertaken. RADIOLOGIC STUDIES The special tests which tance follow.

should be performed

in order of impor-

ULTRASONOGRAPHY .-This relatively inexpensive and noninvasive examination has become increasin 1 useful in the diagnosis of obstructive jaundice. 35, 38, 41,48, 118 &4, 188, 189,202, 209 The examination is highly reliable in defining dilatation of the intrahepatic ducts. Deitch studied the measurement of the ductal system by ultrasonographic examination and by direct measurements in the operating room. Direct measurements agreed with ultrasonic measurements in 85% of his patients. An analysis of the size of the duct indicated that extrahepatic bile duct obstruction was present if the extrahepatic duct was 1.0 cm or wider or if the intrahepatic bile duct was in excess of 0.5 cm. If the extrahepatic bile duct measured less than 0.8 cm sonographically and the intrahepatic duct 0.4 cm or less, obstruction was not present.48 In many instances, stones in the external biliary tree also may be observed and it may be possible to make an absolute diagnosis of choledocholithiasis (Fig 4).‘03 When positive, the reliability is extremely high; when negative, the reliability is poor. The common duct may not be dilated, even though choledocholithiasis is present, and the visualization of small stones may be obscured by overlying gas shadows. COMPUTERIZED AXIAL TOMOGRAPHY (CAT SCANNINGkThe use of computerized axial tomography in the diagnosis of biliary tract obstructive disease is favored by some.78 There is no question concerning the fact that dilatation of the intrahepatic ductal system may readily be seen by this technique, and dilatation 737

Fig 4.-A, ultrasound demonstrating B, dilated intrahepatic ducts demonstrated

dilated ducts and on CAT scan.

stones

in the gallbladder.

of the extrahepatic ducts may also be seen.g5T ‘*‘, 147715’ It does not have a higher reliability in the detection of gallstones than does ultrasonography. It is perhaps more accurate in the delineation of masses in the head of the pancreas, and thus, more helpful in the differentiation of other causes of obstructive jaundice. It is not always possible to differentiate between an enlarged head of the pancreas due to pancreatitis and that due to malignant disease, however. Consequently, if the ultrasonographic finding is not diagnostic, this author does not spend ad738

ditional time and money utilizing this noninvasive test, but proceeds directly to radiographic visualization of the common bile duct by endoscopic retrograde cholangiography. ENDOSCOPIC

RETROGRADE

CHOLANGIOPANCREATOGRAPHY

(ERCPL-This technique allows visualization of the stomach and duodenum to aid in ruling out other lesions that might be a factor in the source of obstructive biliary tract symptoms. It also will allow the direct inspection of a choledochoduodenal fistula should such a lesion exist.‘j’, “I It allows visualization of the pancreatic duct, and a successful ERCP is as diagnostic in delineatin common duct pathology as any other available examination. ’ $’ lg4, lg6, ‘12 Furthermore, with this technique, one can also obtain samples of bile for examination as well as samples of pancreatic secretion. In a study of patients with the post cholecystectomy syndrome reported by Cooperman et al. this examination was abnormal in 52% of 42 patients.43 In addition to the findings of choledocholithiasis, papillary stenosis and sclerosing cholangitis, lesions in the pancreas were also found, which explained the symptoms. The most common abnormal finding, however, was choledocholithiasis, which was documented in 35% of those patients in whom the studies were abnormal. Although in expert hands the success rate of ERCP is quite high, in some patients a patulous sphincter of Oddi, previous sphincterotomy or other abnormalities will make filling of the biliary tract difficult. Ikeda et al. have utilized a balloon catheter to occlude the distal duct in such cases, and with this modification of technique have been able to fill the entire ductal system satisfactorily with good diagnostic accuracy.g3 When satisfactory visualization of the common duct cannot be obtained, the author recommends immediate utilization of percutaneous transhepatic cholangiography (Fig 5). PERCUTANEOUS TRANSHEPATIC cHoLANcIocRAPHY.-With the use of the small thin needle, the success rate of this technique is excellent and the complication rate is 10w.~~76, go>i6’ Nevertheless, it is an invasive procedure, and will only delineate the biliary ductal system. For this reason, it should be used when ERCP fails. This technique can delineate the size and anatomy of the ductal system and the site of an obstructing point. The accuracy in differentiation between stone, carcinoma and benign stricture is quite high, though not absolute. Regardless of the radiographic findings, a final diagnosis of the nature of an obstructing lesion must always be made at operation. INTRAVENOUS CHOLANGIOGRAPHY.-Prior to the development of ERCP and percutaneous transhepatic cholangiography, this was the best examination available for visualization of the common bile duct.64S *‘, g7, is6 This test, however, had many deficien-

Fig ductal

5.-Endoscopic system with

filling

retrograde defects

cholangiogram demonstrating compatible with common duct

a markedly stones.

dilated

ties: (1) There was a significant incidence of undesirable side effects due to reactions to the intravenous dye; (2) repeated exposures over a prolonged period were necessary; (3) visualization of the duct was missed in some patients because of delayed dye excretion, (4) although accuracy was increased by the use of tomography, even these examinations could be difficult to interpret; and (5) the test was often not diagnostic. When positive, intravenous cholangiography produced a high degree of accuracy with pathology delineated in over 80% of patients in whom a positive test was recorded. A negative test, however, does not exclude disease. This test is obsolete. RADIOISOTOPE

STUDIES

ROSE BENGAL SCANNING.-Radioactive agents to aid in evaluation of jaundice has been available for many years. In children, the use of ERCP and percutaneous transhepatic cholangiography can be extremely difficult, as well as hazardous, and there740

fore, this noninvasive technique has been popular. However, day it has largely been replaced by HIDA scanning.

to-

HIDA sCANNING.-Technetium-99-m-N-(2,6-diethylphenylcaracid (IDA), technetium-99mbamoylmethyl)-iminodiacetic N-(2,6-dimethylphenylcarbamoylmethyl)-iminodiacetic acid technetium-99m-N-(p-butylphenylcarbamoylmethyl)(HIDA), iminodiacetic acid (BIDA), technetium-99m-(2,6 diisopropylphenylcarbamoylmethyl)-iminodiacetic acid (DISIDA), and technetium-99m-(p-isopropyl acetanilidoj-iminodiacetic acid (PIPIDA) are newer radioactive materials utilized in the diagnosis of jaundice in adults and children. In adults, HIDA scanning has been quite accurate in the diagnosis of complete biliary tract obstruction, but its accuracy in incomplete obstruction and the ability of the test to delineate the etiology of the obstructing agent is much lower than that of ERCP or transhepatic cholangiography, and therefore, in the opinion of the author, it should be utilized only under special circumstances in which the other two tests are contraindicated or unsatisfactory.l’*j 158,204 In the opinion of many pediatricians, however, it is the procedure of choice for evaluation of possible ductal obstruction in children.

PREOPERATIVE CHOLEDOCHOSCOPY TRANSORAL TRANSDUODENAL CHOLEDOCHOSCOPY.-The optimum method for examination of the common duct should be by direct inspection, but until recently, there have been no instruments that would allow such an examination. The Japanese, who led the way in developing fiberoptic instrumentation, have now developed a very small optical instrument that can be introduced through the ampulla of Vater in the same way as the catheter for injection of dye in performing endoscopic retrograde cholangiography.134 Experience with this procedure is limited and there are few centers in which the procedure is available at all. Techniques are being developed, however, and photographs of lesions taken through this minute endoscopic equipment have been published and show relatively good definition. With the tremendous advances which have been made in fiberoptic equipment within recent years, it is entirely possible that this technique may become the procedure of choice for examination of the extrahepatic biliary tree within the next few years. RISK FACTORS The mortality rate for operations on the common duct is usually listed as approximately three percent, a rate approximately three times that of simple cholecystectomy. There are many factors that can be identified as increasing the risk.15’ The risk is higher in patients over 60 years of age, in those with associated 741

serious illnesses such as a recent myocardial infarction or renal failure, with sepsis, with serum bilirubin concentrations over 10 mg %, hematocrit below 30%, serum albumin concentration below 3.0 gm % and alkaline phosphatase concentration less than 100 units. In the United States, the presence of septic shock, unresponsive to antibiotic fluid replacement and conservative therapy, has been associated with virtually 100% mortality rate. In the experience of this author, the mortality rate is also markedly increased in patients operated upon during the acute course of pancreatitis. Aranha and associates have called attention to the high mortality rate of cholecystectomy and common bile duct exploration in patients with cirrhosis.6 This factor assumes some importance since autopsy studies have shown that the incidence of cholelithiasis in patients with alcoholic cirrhosis is double that seen in noncirrhotic patients. The most significant predictive factor was prolongation of the prothrombin time. In patients without cirrhosis, the mortality rate for cholecystectomy with or without common duct exploration was only l.l%, while in patients with cirrhosis and normal prothrombin times, the mortality rate was 9.3%. The mortality rate was 83.3% in 12 cirrhotic patients with prothrombin times more than 2.5 seconds greater than those of the control. Six of these twelve patients had common duct exploration, and only one survived. PREOPERATIVE

PREPARATION

The patient undergoing elective cholecystectomy, in whom there is no evidence of common duct disease, needs no special preoperative preparation other than permission to explore the common duct if indications for exploration are found at the time of operation. Those patients with severe associated disease should have optimal control of abnormalities prior to the time that operation is undertaken. There are special considerations, however, in patients with suspected or known choledocholithiasis.” JAUNDICE

Because of the increased operative risk in patients with jaundice, the author prefers to give such patients a trial of conservative therapy, and in most patients, resolution of the jaundice will occur, allowing safe operation at the time of election. If jaundice does not improve, and particularly if it deepens during the first 24-48 hours of treatment, operation should be undertaken before severe secondary sepsis occurs or secondary hepatic damage develops. Preoperative percutaneous transhepatic decompression of the biliary tract has been advocated when the initial serum bilirubin concentration is very high.4g, 13~,lg5 This 742

technique has been used more extensively in patients with complete biliary tract obstruction due to carcinoma, but it is occasionally indicated in choledocholithiasis.2g Pollock and associates in a report of 41 patients with obstructive jaundice treated in this manner included six patients (14%) who had common duct stones.152 Because the biliary tract is usually dilated in such patients, the experienced radiologist can cannulate the ductal system by percutaneous puncture and establish external drainage.5g In many patients, the drainage catheter can be passed beyond the obstructing point into the duodenum and thus provide internal drainage as well (Fig 6). The possibility of clotting abnormalities always exists in patients with jaundice, and the author routinely administers vitamin K systemically prior to operation, even though tests of coagulation are normal. (See the section on complications.) SEPSIS

Patients with fever, with or without chills, should be treated with broad spectrum antibiotics preoperatively, during the opFig 6.-Roentgenographic picture of a percutaneous transhepatic catheter passed through an area of stricture of the common bile duct and into the duodenum. This allowed external drainage and reduction in the high serum bilirubin concentration prior to operation. In this patient, there was a combination of complications due to pancreatitis and choledocholithiasis.

eration and postoperatively. There is not general agreement upon the exact choice of antibiotics, but more than one antibiotic should be administered to cover the spectrum of the known common bacteria (see the section on complications). PROPHYLACTIC

ANTIBIOTICS

In the absence of active infection, some clinicians recommend prophylactic antibiotics, even though no clinical infection is present. Gunn conducted a controlled trial of prophylactic use of antibiotics in patients having a dilated common duct due to choledocholithiasis.81 Seven criteria for selection of patients for the use of prophylactic antibiotics included: 1. Age greater than 50. 2. Previous history of jaundice. 3. Empyema of the gallbladder. 4. Abnormal liver function tests. 5. A nonfunctioning gallbladder on oral cholecystography. 6. A dilated common bile duct. 7. A stone or stricture in the common bile duct. Prophylactic antibiotics were utilized if three or more of these criteria were present. Thirty patients were randomized to receive prophylactic antibiotics or not. There were 10 infectious complications in the control group, including wound infections, subphrenic abscesses and five patients who developed septic shock, but in the treated group, there were only two-one wound infection and one subphrenic abscess. Keighley, as well as others, has also observed a significant reduction of wound sepsis, as well as a reduction in septicemia, when prophylactic antibiotics were administered to patients having a high likelihood of positive bile cultures.100 INDICATIONS FOR EXPLORATION OF THE COMMON DUCT IN PATIENTS WITH CHOLELITHIASIS

BILE

Although the diagnosis of choledocholithiasis can be made preoperatively in most patients, expensive, invasive studies are not indicated in patients with proven cholecystitis and cholelithiasis in whom operation is planned. In these patients, preoperative clinical features, findings at the time of surgical intervention and intraoperative cholangiography will suffice. The classFss ix$ications for choledochotomy include the following. ’ ’ PREOPERATIVE

EVALUATIONS

JAUNDICE.-The presence of obstructir~e jaundice is considered one of the absolute indications for choledochotomy when performing cholecystectomy for cholelithiasis. If the patient has no 744

jaundice at the time of operation, and the presence of jaundice is simply a historical feature, it must be assured that jaundice was not due to some other disease process such as hepatitis. Furthermore, a certain percentage of patients with acute cholecystitis will have ascending cholangitis which will produce low levels of jaundice in the absence of common duct stones. Some authors have maintained that a serum bilirubin concentration below the level of 3 mg % is most likely due to ascending cholangitis and thus should not indicate the need for choledochotomy, while a serum bilirubin concentration above the level of 5 mg % is almost always the result of obstruction. The use of intraoperative cholangiography to aid in further decision making will be discussed later. The author has utilized the presence of jaundice, with laboratory data typical of obstruction, as an absolute indication for common duct exploration. While it is true that the yield of finding stones in patients with mild jaundice is less than in those with high serum bilirubin concentrations, stones have been found in patients whose highest serum bilirubin concentration was only 2 mg %. CHILLS AND FEVER.-High fever may occur in patients with gallbladder disease, but when frank chills occur, common duct obstruction is likely. Frank chills and high fever have thus classically been used as an absolute indication for common duct exploration and, in the opinion of the author, should remain so. PANCREATITIS.-AS noted elsewhere, there are those who believe that gallstone pancreatitis is caused in almost all cases by the passage of stones through the common bile duct. On the other hand, the exploration of the common bile duct in patients undergoing elective cholecystectomy for cholelithiasis and with a past history of pancreatitis does not reveal common duct stones with a higher incidence than the average for patients without pancreatitis. In a collected series of 599 patients with the incidence of common duct acute gallstone pancreatitis, stones averaged 18%, which is within the range reported in patients with gallbladder disease without pancreatitis.‘r Other authors believe that the incidence of choledocholithiasis in such patients is quite high, but that many of the stones that cause pancreatitis during their passage through the common duct exit through the ampulla of Vater, and thence through the gastrointestinal tract.’ This author has considered pancreatitis a relative indication for exploration of the common duct when cholecystectomy is performed electively. Many of the abnormal findings to be listed below will, in addition to pancreatitis, be taken as an absolute indication for exploration of the common duct. However, if the common duct is completely normal, no stones are palpated and the duct measures 4 mm or less, cholangiography will be utilized as the final decision-making procedure before actually opening the common bile duct. 745

RADIOGRAPHIC EVIDENCE OF STONES ORDILATED mcm.-Specific diagnostic tests to demonstrate ductal pathology are used infrequently in patients with proven gallbladder disease, but ductal abnormalities or stones demonstrated by ultrasound, CAT scan, ERCP or transhepatic cholangiography are absolute indications for ductal exploration. OPERATIVE FINDINGS PALPABLE STONE INTHE COMMON DUCT.--The entire external biliary tract must be carefully palpated-from the liver to the ampulla of Vater-for the possible presence of stones. This is the first maneuver in the examination of the common bile duct. The presence of a palpable stone is considered by all surgeons to be an absolute indication for exploration of the common bile duct. Way and associates reported 98% ,positive explorations when this finding was present (Table 51.” DILATATION OF THE COMMON BILE DUCT.-Marked dilatation of the common bile duct is considered an absolute indication for exploration by virtually all surgeons.203 The only difference of opinion concerns the degree of dilatation required. It is generally agreed that the normal common bile duct rarely exceeds 1 cm in diameter, and thus, a common duct measuring 1.5 cm would uniformly be accepted as abnormally large. On the other hand, it would be unusual to find a common bile duct measuring even 9 mm in a female patient of slight build who weighs no more than 100 pounds. THICKENED COMMON BILE DUCT.-This is considered a very strong indication for common duct exploration, as thickening of the bile duct indicates the presence of chronic inflammation. A thickened bile duct may also mean the presence of carcinoma or sclerosing cholangitis, and in some patients the common duct will be thickened because of the adjacent inflammatory disease

TABLE

S.-RELIABILITY

OF INDICATIONS EXPLORATION*

FOR COMMON

RESULTS INDICATION

OF EXPLORATION POSITIVE %

Palpable stone Cholangitis with jaundice Positive intravenous cholangiography Positive pre-exploratory cholangiogram Pancreatitis Jaundice Dilated duct Small stones *From Way L.W., Admirand

746

DUCT

W.H., Dunphy J.E.“’

98 94 83 50 50 35 14 10

from repeated attacks of cholecystitis, particularly when the common duct has become involved in a severe inflammatory process. THE PRESENCE OF SLUDGE.-After removal of the gallbladder, the common duct should be “milked” to empty bile out of the cystic duct to note its character. Even though stones cannot be palpated in the common duct, small stones or “sludge” in the common duct may be milked out in this fashion. SMALL STONES IN THE GALLBLADDER.-While this has been utilized as an absolute indication for common duct exploration by some surgeons, the majority, including the author, utilize this as a relative indication and explore the common duct only if there are additional findings. While there is no question that small stones may enter the common duct through a relatively larger cystic duct, all stones in the gallbladder were small at one time and such passage could occur. Thus, there is probably no patient with cholelithiasis in whom passage of stones from the gallbladder into the common duct could not have occurred at some time and the simple fact that operation is performed at the stage when stones are still small has not, in the experience of the author, increased the probability of finding common duct stones on exploration. INTRAOPERATIVE cHoLANGIoGRApHY.--Intraoperative cholangiography was described by Mirizzi in 1932, but its role as the deciding factor for exploration of the common duct is not agreed upon by all surgeons. iz6 The majority opinion advises a cystic duct or needle cholangiogram in all patients having cholecystectomy. The cystic duct cholangiogram is accomplished during gallbladder removal. A number of catheters are made for this purpose. The catheter and syringe must be filled with contrast media, freed of air bubbles and inserted into the cystic duct without trapping air during the insertion. Either one or two films may be taken-the first taken after injection of only 5 cc of dye and the second after injection of a quantity of dye judged sufficient to fill the entire ductal system. While the films are being developed, the cholecystectomy may be completed and the findings on cholangiography used to determine the need for exploration of the common duct. There is general agreement that the common duct should be explored when suspicious lesions are observed on cholangiography and, in questionable cases, cholangiography may be the final deciding factor for exploration of the common duct. Many surgeons, however, also use a negative choledochogram as evidence that the common duct does not need to be explored, under circumstances in which there were other relative indications for explorations. The author has not utilized intraoperative choledochography routinely in all patients undergoing cholecystectomy, but rather has utilized it selectively. 747

Both false negatives and false positives occur, and to presume that intraoperative cystic duct cholangiography provides an absolute answer concerning the need for common duct exploration is a mistake.36* 46 In the study by Way and associates a positive pre-exploratory cholangiogram yielded positive findings upon opening the duct in only 50% of the cases.2oo Others have found a much higher incidence of positivity of stones. Air bubbles in the biliary tree and other debris such as small blood clots emanating from the transection of the duct or the insertion of the catheter may be mistaken for gallstones. la5 Causes of error are described in more detail in the discussion of intraoperative T-tube cholangiography. Bordley and Olson have observed that spasm at the sphincter of Oddi frequently impedes flow of cholangiographic dye into the duodenum. 7 A variety of agents to relax the sphincter have been used, including amyl nitrate and nitroglycerin. These agents, however, are not always effective in the anesthetized patient. These authors have found the use of glucagon to be effective in accomplishing this objective. One milligram of glucagon is injected intravenously. Sphincter relaxation usually occurs within two to eight minutes. They reported 100% success in 10 patients in whom it was used.27 Cholangiography is an adjunct in the decision-making process and the findings must be correlated with the remainder of information available preoperatively and intraoperatively. OTHER OPERATIVE FINDINGS.-Other operative findings that have been used include a gallbladder empty of stones in a patient with biliary tract symptoms, a small contracted gallbladder, fistula and a single-faceted stone in the gallbladder.i’, 3g3ls4 INDICATIONS FOLLOWING

FOR COMMON DUCT EXPLORATION PREVIOUS CHOLECYSTECTOMY

Evaluation of the possibility of common duct pathology is indicated in any patient having symptoms in the right upper quadrant in the later postoperative period following cholecystectomy. The techniques described for evaluation of the patient with jaundice should be followed in all such patients. Even though jaundice is not present, an elevation of the serum alkaline phosphatase value may be found. Ultrasound may demonstrate dilatation of the intrahepatic and/or extrahepatic ducts. If these examinations are not diagnostic, ERCP should be performed to determine the size of the ductal system and the presence or absence of stones in the common duct with specific attention to the stump of the cystic duct, which may be harboring stones. This examination will also aid in excluding other causes of symptoms. 748

EXPLORATION

OF THE COMMON

BILE DUCT

TECHNIQUE

The first step in exploration of the common bile duct is to identify the duct, unequivocally. While this seems a rather simple statement, the common bile duct can be mistaken for other structures in the porta hepatis, because anomalies, as indicated in the section on anatomy, are quite frequent. When planning to open the common duct, therefore, the first maneuver is aspiration of the structure which is to be opened to be sure that it contains bile. If it contains blood, it should preferably be left unopened. One of the author’s mentors taught the importance of routinely aspirating the duct, but on one occasion, after performing several thousand biliary procedures, he did not do so. He opened the portal vein, believing it to be the common duct, despite his extensive experience. This occurred before the development of vascular clamps and modern vascular suture materials. One may inadvertently open either the right or left duct when anomalies exist, and particularly troublesome can be an opening into a cystic duct which is contained within the sheath of the common duct, showing a lumen much smaller than had been anticipated. When anatomy is obscure, cholangiography can be helpful in decision making. Exploration should begin by simple inspection and palpation before opening the duct. The incision is made in the common bile duct distal to the entrance of the cystic duct so that the cystic duct entrance can be inspected thoroughly. Also, the incision should be in the largest portion of the duct where the possibility of stricture formation will be minimal. Gentle massage of the duct from the liver toward the choledochotomy and from the ampulla toward the choledochotomy may allow removal of the stones. Exploration of the distal duct is normally undertaken next, as this is the area in which stones are most commonly found. Instruments used routinely should be probes, scoops and stone forceps. Occasionally one will identify a stone and extract it successfully with one of these instruments when it was missed with the others. In performing these procedures, it is important to be sure that a Bakes dilator passes entirely into the duodenum to be sure that there is not a stone in the most distal end of the duct. A similar exploration is performed in the upper biliary tract, entering specifically the right and the left intrahepatic ducts in the usual fashion. The next procedure is thorough irrigation of the ductal system in all directions, making sure that irrigation fluid enters the duodenum freely. Many surgeons irrigate through a rubber or plastic catheter. The author agrees with those who use a metal irrigator. It can be placed more easily and accurately, and more forceful irrigation is possible. 749

Dilatation of the sphincter during exploration of the distal duct is controversial. All agree that it is necessary to pass an instrument completely into the duodenum to ensure patency of the sphincter and the absence of a distal occluding stone. The author continues to perform dilatation of the sphincter to the size of the duct, up to 10 mm, as an aid in exploration of the distal duct and to enlarge the sphincter so that any residual debris or small stones can easily pass into the duodenum. Almost 20 years ago, Fogarty devised a catheter for use in vascular surgery to remove emboli and thrombi from the arterial tree. It soon became apparent that this catheter could be used to remove material from other tubular structures as well, and in 1968, Fogarty and associates reported the use of a pliable balloon catheter for use in the biliary ductal system.62 Two catheters were described at that time, the smaller measuring 1.5 mm and the larger measuring 2 mm in diameter. The balloon of the smaller instrument inflated to a maximal diameter of 8 mm, while in the larger catheter, the balloon inflated to a maximal diameter of 18 mm. The over-all length of the catheter was 25 cm, considerably shorter than that used in vascular surgery. In their report of 1968, the authors described its use in 75 common duct explorations and compared the results in these patients with 75 patients having had common duct exploration without the use of the catheter. Only four patients (5%) had retained stones when the Fogarty catheter was used, as compared to 10 patients (11%) when the catheter was not used. Since that time, the Fogarty catheter has become a standard instrument for use as an aid in extracting stones from the biliary tract and remains a part of the general armamentarium of stone removal. A number of other instruments and procedures can be used to aid in the exploration and extraction of stones from the common bile duct. None are used routinely by all surgeons, and some are used by only a few enthusiasts. Any instrument which aids the surgeon may be useful, for good technique is the most important factor 71,144,177 White and associates called attention to the use of manometry in 1972, pointing out that this technique is commonly used in many European clinics. Several types of apparatus are in use. They also reported their experience with flow studieszo7 They report that a common bile duct pressure above 16 cm of saline is a reliable indication of abnormality in the duct or sphincter, but it must be used in conjunction with cholangiography, since there is a 3.5% incidence of false negative results and a 4.5% incidence of false positive results. When pressure studies and cholangiograms are combined, the incidence of false negative results is reduced to 2.5% and that of false positive results to 3%. When flow measurements, pressure measurements and cholangiograms were utilized, 99.1% accuracy was obtained. Stones affect pressure and flow only in the distal duct. The technique is 750

not useful in determining of the biliary tree.

the presence of stones in the upper part

CHOLANGIOGRAPHY

Many surgeons recommend intraoperative cholangiography routinely in all patients undergoing common duct exploration to define pathology before the duct is opened. Injection through the cystic duct is the standard technique if cholecystectomy is to be performed. Direct needle puncture of the duct is also employed. lo3, i3*, 157 Not all agree, however, that a pre-exploratory cholangiogram saves time. In fact, in some institutions, it would appear that it adds to the time of common duct exploration without reducing the incidence of retained stones. There is consensus, however, that cholangiography the duct is closed.16

should

be performed

before

Despite care in the performance of cholangiography, it is possible to miss stones in the common bile duct. The sources of error are numerous. 82 They include: INADEQUATEVI~UALIZATIONOFT~~E

ENTIRED~~TALSYSTEM.-

The entire ductal system must be visualized and it must be assured that there is no obstruction at the ampulla of Vater. Dye does not flow readily into the duodenum in all patients during operative cholangiography. In some instances, the flow is impeded because of anesthetic medications, particularly large doses of morphine. In others, there is spasm of the ampulla of Vater secondary to dilatation and the mechanics of exploration. When dye does not flow freely through the ampulla there are several approaches to elucidate this problem. One is the use of glucagon to produce relaxation of the ampulla of Vater. A second is the insertion of a catheter through the ampulla into the duodenum and the injection of dye through this catheter as it is withdrawn. This will demonstrate that there is patency of the ampulla of Vater and will visualize the entire distal common duct and duodenum satisfactorily. The third technique, as will be mentioned subsequently, is the use of the choledochoscope with passage of this instrument through the ampulla for direct visualization of these areas. In some patients, filling of the entire ductal tree may be difficult. Placement of Fogarty catheters with inflated balloons proximal and distal to the choledochotomy and the injection of dye through a small catheter held in place by the balloon will prevent leakage of contrast material and ensure adequate filling of the ducts. OVERFILLING THE DUCTAL SYSTEM.-The

test is usually

per-

formed as a flush technique, and therefore, the volume of dye is not readily controlled. Some surgeons, therefore, routinely take

two pictures before looking at the films. For the first picture, only 5 ml is injected, hoping to cover only the posterior wall of the duct; while in the second, enough dye is injected so that the ductal system will be filled. The ducts may be overfilled so that a stone is obscured by the dye. Installation of a fluoroscope with an image intensifier within the operating room can improve intraoperative radiography. With this equipment, intraoperative cholangiography should approach the accuracy of that in the radiology department and reduce the incidence of retained stones.ig The high cost of such equipment and the space needed for installation has precluded the use of this technique in most hospitals. IMPROPER POSITION.-If the patient is not properly positioned, the duct may overlie the spine and detail is obscured. AIR BUBBLESIN THEINJECTEDDYE. MOVEMENT OF STONES DURING INJECTION.-AS the dye is injected forcefully, this may cause the stone to roll. NO filling defect will be seen on the film. OBSCURE FIELD.-overlying

instruments

or packs

may

ob-

scure the field. It is important to remove all packs with incorporated radiopaque material within them and to remove all instruments and retractors from the field before the cholangiogram is taken. TECHNICAL PROBLEMS WITH EXPOSURE.-This

is particularly

true in the obese patient for whom the equipment may have inadequate penetrating power. Accurate measurements of body girth should be recorded prior to the time that the operation is begun and, ideally, a scout film should be taken before the cholangiogram is performed to ensure proper technique. FAILURE OF PROPER INTERPRETATION.-The

film

should

be

completely developed and dried in the film processor before being evaluated and each film should be evaluated by a radiologist, as well as the surgeon, for confirmation. FAILURE TO REPEAT EXAMINATION IN QUESTIONABLE CASES.-

At times what appears to be a minor abnormality will be noted, but because it does not resemble a stone and because the technician may be busy somewhere else at the time, a film is not repeated. A stone may be discovered on the postoperative cholangiogram. R~~~~10~~0~0~~~~~~~EDIuM.--Althoughuncommonunder

anesthesia, reactions may occur and make it necessary to discontinue the procedure. Hicken and McAllister reviewed records of 486 patients treated between 1952 and 1956 in whom cholangiography was not performed in their hospital, and found an incidence of residual stones of 19%.88 Between 1957 and 1962, there was an in752

creased use of cholangiography and the incidence of residual stones decreased to 11%. In collected data representing the work of 30 surgeons in their community, a series of 407 cases in which completion cholangiography was used in all cases disclosed an incidence of residual stones decreased to 4%. All surgeons, however, have not been as successful in reducing the incidence of retained stones. Hall and associates in a survey of three Syracuse hospitals found retained stones in 14% of 302 patients studied. In 30 of the 41 patients with retained stones, operative cholangiography had been performed after surgical exploration, and had failed to disclose stones. These authors warn against undue reliance upon cholangiography.s2 CHOLEDOCHOSCOPY

Direct inspection of the interior of viscera is a standard method of examination of the colon, the bladder, trachea, esophagus, and stomach with or without special optical equipment. Direct inspection should provide the best means of examination and the most accurate delineation of pathology. It is thus strange that surgeons have persisted in the use of indirect methods of examination of the common bile duct. A rigid instrument specifically for this purpose was designed by McIver in 1941.123 Several years later, Wildegans devised a flexible optical instrument.‘08 These instruments did not gain popularity partly because of poor optical systems and reports of severe complications. Only within recent years has there been a renewed interest in choledochoscopy. The current wave of enthusiasm followed the development of the Hopkins lens system, and the early studies by Shore and associates, allowing excellent visibility through a rigid choledochoscope.178 Subsequently, with improved optical systems incorporated in the fiberoptic instruments, flexible choledochoscopes with good resolution have become available.14 Despite the numerous reports which now appear in the literature advocating the use of these instruments and documenting the ability to discern pathology with their use, the majority of surgeons do not use the instruments routinely and many have not used them at all. A prospective cooperative study was reported from several institutions.r3’ The incidence of overlooked stones in some institutions was reduced to zero, while in others the choledochoscope did not improve the incidence of retained stones as compared to the control group. In 1980 we reported our experience with the use of the rigid choledochoscope in 140 patients-a study in which a number of senior surgeons and residents participated. 54 The use of the choledochoscope did not reduce the incidence of retained common duct stones as compared to a group in which it was not used. However, the two series were not completely comparable. The choledochoscope was used selec753

tively by some surgeons, more commonly in patients with multiple stones in whom the likelihood of missing the stone was greater. Bauer and associates reported the use of the flexible fiberoptic choledochoscope in 52 patients. Only one calculus (2%) was missed. Rattner and Warshaw, in reviewing an experience with 144 choledoscopic examinations performed in the course of 499 common duct explorations for stones found no complications with only 15 to 20 minutes of additional operating time.16’ In 24% of patients additional stones were discovered with the choledochoscope after completion of routine bile duct exploration. However, the overall incidence of stones (4%) was not changed by the examination. Our experience agrees with others that the choledochoscope has several advantages. (1) Stones are identified which were missed by other means of examination, including cholangiography. (2) The choledochoscope is an aid in removal of certain stones, particularly those in the liver. It is equipped with an irrigation channel which may aid in removing the stones, and it allows use of a variety of instruments under direct vision. Of particular importance is the ability to pass a Fogarty catheter under direct vision to aid in stone removal. (3) It will allow positive identification of the cause of deformations which may be seen on intraoperative cholangiography. What appears to be a stone on cholangiography may be an air bubble, a blood clot or a polypoid tumor, rather than a stone. Thus, direct inspection with a choledochoscope can delineate the precise pathology with accuracy. (4) Tumors of the ductal system which might be missed by cholangiography can be directly visualized, and direct biopsies can be taken for histologic examination. (5) Ductal anomalies can be delineated. A stone may be seen in a diverticulum of the distal duct, which might be missed by other techniques. (6) Other types of intraductal pathology may be identified. ‘, 143,153 We, for example, have found liver flukes within the ducts, and others have observed round worms and other parasites. There have been no complications due to choledochoscopy our experience or in the reports in the recent literature.

in

We have used the rigid choledochoscope because of the excellence of the lens systems. The choledochoscope can be inserted through the standard choledochotomy incision, passed upward and subsequently down the ductal system. The 7 mm length of the scope will allow passage to a point that permits one to see into the secondary, and frequently into the tertiary ductal system of the liver. The instrument is then removed and passed distally through the ampulla of Vater. The author prefers to dilate the ampulla of Vater up to at least 5 mm before inserting the choledochoscope, which has a diameter of 4 mm. This dilatation ensures passage through the ampulla of Vater. Ross has emphasized the need to perform a complete examination of the 754

biliary tract with the choledochoscope, a recommendation with which the author fully concurs. He recommended the insertion of a Fogarty catheter into the duodenum with the balloon inflated. The operator should visualize the balloon before the examination is complete.162 The author has not found this necessary. The appearance of duodenal mucosa is quite different from that of ductal mucosa and, furthermore, one can ensure the presence of the choledochoscope within the duodenum in the same way as in passing a Bakes dilator. Failure to ensure the complete passage through the ampulla of Vater is one of the reasons for insuccess, however. During the entire period of examination, continuous irrigation of the biliary ductal system is maintained through the appropriate channel on the choledochoscope. The irrigation serves several purposes. Of most importance, it keeps the ductal system clean of debris during the examination. But of equal importance is the maintenance of dilatation of the ductal system in order that good inspection can be accomplished. Pressure can be maintained by placing a blood pump around the bag so that the fluid is irrigated under high pressure if necessary. Also, the opening in the choledochotomy incision can be partially closed around the choledochoscope if necessary to maintain adequate pressure for visualization. During our use of the choledochoscope, the operating surgeon and the first assistant, independently inspect the entire ductal system. The author has not performed an operation for choledocholithiasis in the past 8 years without using the choledochoscope and is convinced that it is an extremely valuable addition to the surgeon’s armamentarium for identification and removal of calculous material. Since using the choledochoscope, the author has never found an unexpected retained stone in the distal common duct on a postoperative cholangiogram. Retained stones which have occurred were suspected or demonstrated by intraoperative cholangiography in the intrahepatic ducts where successful removal was not possible. The flexible choledochoscope is utilized in the same manner as that described above, and in some patients manipulation may be easier than with the rigid choledochoscope. Experienced surgeons should not have difficulty with the rigid choledochoscope, however, since the standard exploration of the common duct is accomplished with many rigid instruments. The reasons given by individuals not using choledochoscopy at the present time are: (1) unfamiliarity with the equipment, (2) insecurity concerning the value of the instrument, (3) fear of complications and (4) unavailability due to the high cost of the instrument. The author is convinced that those individuals who use the choledochoscope regularly as an adjunct will reduce the incidence of retained common duct stones. It should be recognized, however, that it is not a substitute for other means of examination. All standard techniques, including cholangiogra755

phy, should be used. It is used as an adjunct. In those institutions where choledochoscopy is regularly used, however, the delineation of the cause of an abnormal intraoperative cholangiogram can more rapidly and economically be accomplished by choledochoscopy than by repeated cholangiographic studies. It is possible to use other fiberoptic instruments to examine the common bile duct when a choledochoscope is not readily available. In fact, Berci and Hamlin have found problems with use of a fiberoptic choledochoscope with an outside diameter of 6.3 mm, for there are many ducts into which it will not fit.” Because of the large size, they have utilized the flexible fiberoptic bronchoscope which has the outside diameter of 4.8 mm and is more easily inserted. Barnes has pointed out that the flexible bronchoscope is available in most hospitals, and thus, in those institutions where common duct explorations are not performed with sufficient frequency to warrant purchase of an instrument specifically for common duct exploration, the fiberoptic bronchoscope will serve this purpose.” The pediatric bronchoscope is even smaller in diameter, and thus, can be used in small ducts. A flexible nephroscope could be used in a similar manner. Therefore, choledochoscopy should be possible in all hospitals. When one considers the cost of intraoperative cholangiography and the fact that multiple films often must be exposed before a difficult problem is elucidated, the use of choledochoscopy has the potential of saving money rather than adding to the cost of operation (Fig 7). INTRAOPERATIVE ULTRASOUND

Having proven valuable in the preoperative assessment of the size of biliary ducts and the presence of stones, intrao erative use of ultrasound has been evaluated in a few centers.i’ B’ 17’ The author has had no experience with this technique, but data from the literature indicate that the standard ultrasonic probe normally used is not satisfactory and that special equipment for small parts ultrasonography is necessary. This instrument is most commonly used for ultrasound of the region of the neck. For use in biliary tract disease gas sterilization is required. Sigel and associates reported the use of operative ultrasonography in 50 operations on the biliary tract or pancreas.i7’ Fortythree biliary tract examinations were performed. Common duct exploration, operative cholangiography, or both, were performed in 41 of these patients. Common duct stones were identified correctly in 9 of 10 abnormal common ducts, and one intraductal carcinoma. In a comparative study, the authors found ultrasonography equal to or superior to operative cholangiography, and suggested the possibility that this technique might eliminate the need for cholangiography. They emphasized the avoidance of allergic reactions and elimination of radiation exposure. The 756

Fig 7.-A, the rigid choledochoscope. used to examine the biliary ducts.

B, a flexible

bronchoscope,

which

may

be

cost of equipment is $15,000-$20,000. Though a few surgeons have learned to interpret films, most would need an ultrasonographer to interpret the findings. There are no good studies presently available to compare this diagnostic technique with choledochoscopy, but it seems highly unlikely that it would be more accurate diagnostically than choledochoscopy, particularly when stones are in the major ducts. DUODENOTOMY FOR IMPACTED STONES

In the majority of patients, stones in the distal common duct can be removed through the choledochotomy incision. In some 757

patients, however, stones are so impacted in the region of the ampulla of Vater and the associated inflammatory response is so great that extraction from above seems impossible. Under these circumstances, the duodenum should be opened and a thorough exploration of the duct accomplished. A sphincterotomy is performed if necessary to allow extraction of the impacted stones. Choi et al. in a study of 342 patients with primary cholangitis who underwent sphincteroplasty, described impacted stones at the lower end of the common duct as the indication for this operation in 122 of these patients.a7 The author recommends this procedure only when absolutely necessary, for, despite the fact that most duodenotomy incisions heal properly, a lateral duodenal fistula remains a life-endangering complication. INTERNAL DRAINAGE OFTHE COMMON BILE DUCT Sphincteroplasty, choledochoduodenostomy, and choledochojejunostomy have been advocated to provide an opening sufficiently large that residual or recurrent calculi may pass directly into the gastrointestinal tract without causing obstruction. Although there is a general consensus concerning the need for these procedures in selected patients, there is no consensus concerning which technique is preferable or under what circumstances internal drainage should be used. Some authors often use these procedures at the time of the primary operation. Others utilize them almost routinely for retained or recurrent common duct stones, regardless of the number of stones, while still others (and this author falls into this group) utilize them very selectively for retained or recurrent multiple stones.g6’gg Berlatzky and Freund reported 60 patients who underwent side-toside choledochoduodenostomy for benign obstructive disease. Residual or recurrent stones were present in 26 patients, multiple stones in 31, and hepatic stones in eight.” Other patients had radiographic evidence of papillary stenosis or gallstone pancreatitis. Two or more indications were present in most of the patients. In this series, there was no operative or hospital mortality. The average hospital stay was 15 days. In a follow-up period of 1-15 years, all patients but one were free of abdominal complaints. These authors now utilize this procedure more freely at the time of the primary operation. In the last 33 cases, choledochoduodenostomy was performed at the time of the primary, rather than a secondary, operation. In a review of ‘709 patients abstracted from the literature between 1970 and 1979, they found an overall mortality rate of 2.5% for the procedure, with mortality rates ranging from 0, as in their series, to a high of 8.3%. Schein and Gliedman reported 200 patients undergoing choledochoduodenostomy for calculous disease of the biliary tract.i7’ There were seven deaths (3.5%). It was their conclusion that 758

when the common bile duct measures 1.2 cm or greater in its internal diameter, choledochoduodenostomy gives excellent results with a mortality rate not significantly greater than that of simple extraction and T-tube drainage, but they do not recommend choledochoduodenostomy in smaller ducts. The second and third parts of the duodenum can be brought easily into the area of the hilum of the liver. They advocate a 25 mm vertical incision even if the duct is quite wide, with removal of a 2 mm wide section of the anterior ductal wall to allow for a gap at the choledochotomy. A single anastomotic stent is used. Moesgaard et al. found that choledochoduodenostomy was tolerated well even in the elderly.i2’ In a study of 49 consecutive patients more than 70 years of age, there were only two deaths within 30 days of operation. One was from myocardial infarction and one from pulmonary embolus. Neither was directly related to the procedure performed. Follow-up studies in 41 patients from two to eight years following operation revealed only one with recurrent biliary tract symptoms. Choi et al. found the overall mortality rate in their 342 patients undergoing sphincteroplasty to be 4.7%.37 Long-term results were reported as good, with an 8.2% incidence of poor results during an average follow-up of seven years four months. The most common cause of recurrent symptoms, however, was the reformation of stones. Although most authors report a high incidence of good results with biliary intestinal anastomosis, they are not uniformly successful. McSherry and Fisher recently reported six patients who had recurrence of symptoms following biliary intestinal diversion.124 Two of these patients were subsequently treated by endoscopic papillotomy and the others by additional surgical procedures. These authors conclude that a biliary enteric procedure will not always relieve the problem of recurrent or residual stones and that the primary effort at the time of surgery should be directed towards removal of all stones from the ductal system. Choledochoduodenostomy should not be used as a “crutch” for inadequate surgical treatment of common duct stones, but rather, should be used with specific indications, such as obstruction of the distal part of the bile duct. The author agrees with McSherry and Fisher and uses internal drainage only in highly-selected patients. All three techniques have been used, depending upon pathologic and anatomical considerations. Choledochojejunostomy is preferred in most good risk patients. TREATMENT OF ACUTE SUPPURATIVE CHOLANGITIS The treatment of acute suppurative cholangitis due to common duct stones requires decompression of the biliary tract and appropriate antibiotic therapy. Common duct exploration with 759

choledochotomy and T-tube drainage has been considered the surgical procedure of choice. Lygidakis recently reported a randomized group of 48 patients managed either by choledochotomy and T-tube drainage or by choledochotomy and choledochoduodenostomy. There were 4 deaths in the simple drainage group and only 2 in the choledochoduodenostomy group. Lygidakis concluded that choledochoduodenostomy is the procedure of choice and believes that this procedure eliminates the possibility of exogenous contamination through the T-tube as well as providing better drainage.l” Choledochoduodenostomy also prevents further obstruction from any overlooked stones.lli The number of patients studied is too small to allow conclusions, but further studies of this kind are indicated. Studies of treatment of this problem in acutely ill patients with percutaneous transhepatic drainage are also indicated as an initial method to control infection before definitive surgical drainage is attempted. CLOSURE OF CHOLEDOCHOTOMY INCISION

Some clinicians advocate primary closure of the common bile duct after choledochotomy, but this is contrary to the majority opinion.lg7 Although the common bile duct can be closed satisfactorily in many patients, there is an incidence of bile fistula. If adequate drainage is provided, peritonitis and abscess can be prevented, and such fistulas usually close spontaneously. Some fistulas, however, end with fatal secondary infection and others cause prolonged morbidity, including the possibility of stricture. T-tube placement, therefore, is performed partly to provide drainage of the common bile duct and to prevent the development of abscess and fistula formation. The second reason for Ttube drainage is to allow radiographic examination of the biliary ductal system in the postoperative period. A large T-tube should be used when possible, because the T-tube tract may be utilized as a point of entrance for instruments to extract retained stones. The author prefers a 16F or 18F T-tube. When the duct is small, some surgeons place a T-tube larger than the duct by excision of the back wall of the T-tube.30 This provides for the development of a much larger tract than would have been possible by placing a tube which would fit the duct. The author has not utilized this technique, but rather, has placed the largest T-tube which would fit comfortably into the common duct up to a size 20F. The ends of the tube are beveled so that the long end of the bevel comes against the anterior wall to prevent dislodging and a small opening is cut immediately opposite the T portion of the tube as an aid in ensuring good drainage and to increase ease of removal. Prior to placing the T-tube in the duct, its patency should be ensured by irrigation, and the strength of the tube 760

should be checked to prevent breakage at the time of removal. The T-tube should be long enough to prevent accidental dislodgement, but should not occlude the right or left hepatic ducts. It should not be long enough to occlude the pancreatic duct. Although Cattell developed a long T-tube placed completely through the ampulla of Vater into the duodenum, most surgeons fear the complication of pancreatitis produced by obstruction of the pancreatic duct.34 The opening in the common bile duct around the T-tube should be closed with chromic catgut or other absorbable sutures. Closure with interrupted nonabsorbable suture is still used by some surgeons, but there is no evidence to indicate that this technique improves the results. On the other hand, there is evidence to support the concept that silk sutures may fall into the duct and serve as a nidus for stone formation. The author places a double running suture starting at the distal end of the incision, making sure that the opening is tightly closed around the T-arm of the tube. At the end of this procedure, saline is injected under some pressure to be sure that there is no leakage. Should points of leakage be identified, they are reinforced with interrupted sutures of catgut. The operation is terminated with the placement of a Penrose drain in the foramen of Winslow and another anterior to the choledochotomy to prevent peritoneal contamination from possible leakage through the choledochotomy wound. MANAGEMENT

OF INTRAHEPATIC

STONES

Stones may occur in the intrahepatic ducts, having floated up from the common duct after leaving the gallbladder, because of stagnation in the biliary tree due to congenital anomalies such as Caroli’s disease, because of stagnation behind ductal strictures, and, in a small group of patients in the U.S. and larger groups in the Orient, because of stones forming recurrently in the intrahepatic biliary ducts even though the gallbladder has been removed.1279 14i, 211 The majority of these stones can be removed at the time of choledocholithotomy for choledocholithiasis using any or all of the techniques previously mentioned. Thorough flushing of the intrahepatic ducts should always be accomplished, and if residual stones are seen by choledochoscopy or by cholangiography, these stones should be removed by use of a Fogarty catheter or a Dormia basket. Although stones high in the biliary tree can prolong the operative procedure and make it somewhat more complicated, successful removal is achieved in the majority of cases. When stones become impacted in the intrahepatic ducts, with resulting secondary infection, when there are strictures of the intrahepatic ducts preventing their passage, and when marked dilation of the intrahepatic ducts occurs, a 761

serious and life-endangering problem exists. Secondary infection with episodes of localized cholangitis and hepatic abscess may occur. One of the largest series from one institution is that of Sato and associates from Japan.17’ They reported treatment of 100 patients with intrahepatic bile duct stones, the majority being calcium bilirubinate stones. Other reports from Japan by Nagase and associates and by Nakayama and associates also include large series of intrahepatic stones.13” 135 Nakayama and associates collected 1,590 cases from over 160 Japanese institutions. Thus, there was an average of approximately 10 cases per institution. In this large series from Japan 40% of patients had stones in the left hepatic duct only, while only 15% had stones in the right hepatic duct only. The left hepatic duct is the site of predilection. This is fortunate because the management of stones in the left hepatic duct is more readily accomplished than in the right. Many procedures and combinations of procedures have been used. These include attempts at percutaneous drainage and extraction of stones from the infected area, direct surgical attack with drainage and extraction of stones through a hepatotomy, biliary ductal drainage procedures, procedures to drain the biliary duct directly into the bowel by direct anastomosis and in severe cases, formal liver resection may be necessary. Adson and Nagorney in reviewing an experience at the Mayo Clinic found only eight patients in whom hepatic lobectomy was necessary for intrahepatic stones. Most other series in this country, and even in the Orient where intrahepatic stones are more common, include only a few cases of hepatic resection.‘> 156 In Sato’s report hepatic resection was required in 29 patients. Pridgen, in a review of the world literature, was able to find over 250 cases in which hepatic resection was necessary.‘56 Over 15 operations or combinations of operative procedures were utilized in the treatment in the collected series of Nakayama and associates (Table 6). Despite the difficulty of this problem, the long term results were good in 85%, fair in 12%, and poor in only 5.8%. When secondary operations are necessary, the incidence of good results falls significantly, in Simi’s series to 67% good results, 29% fair results, and poor results in 14%.l*’ Complicated intrahepatic stones represent a special problem and optimal management requires mature judgment and familiarity with multiple, often complicated, surgical techniques. Nevertheless, the majority of the patients will have successful outcome even if major hepatectomy is required. POSTOPERATIVE

CARE

No special postoperative care is necessary in most patients, except that antibiotics are administered as indicated and T-tube 762

TABLE

6.--OPERATIVE DUCT OPERATIVE

PROCEDURES STONE*

FOR COMMON

PROCEDURE

NUMBER

Choledochotomy and drainage Alone With spincteroplasty With choledochojejunostomy With choledochoduodenostomy With Billroth II gastrectomy Without Billroth II gastrectomy Partial hepatectomy including left lateral segmentectomy or left hepatic lobectomy Alone With choledochotomy and choledochal drainage Alone With spincteroplasty With choledochojejunostomy With choledochoduodenostomy With intrahepatic cholangiojejunostomy Alone With choledochotomy and choledochal drainage With spincteroplasty With choledochojejunostomy With choledochoduodenostomy Others Total *From

354 362 299 19 122

37

39 42 15 9 14 23 10 8 2 120 1,475

Nakayama

F., Furusawa

T., Nakama

T.135

drainage is ensured. Drains are removed when healing of the choledochotomy wound has occurred. Postoperative cholangiography through the T-tube should be performed in all patients undergoing common duct exploration. This study should be performed on the fifth to seventh day postoperatively. It is important to ensure visualization of the entire ductal tree, including the secondary intrahepatic ductal system, and it is important to ensure free flow of the contrast material into the duodenum. If the examination is within normal limits, the author recommends a schedule of T-tube clamping starting one hour before each meal on the first day, two hours before each meal on the second day, three hours before each meal on the third day, and if this is tolerated, the T-tube is clamped at all times. Thus, the patient may leave the hospital with the T-tube clamped and not be concerned about drainage from the T-tube. The T-tube can then be removed in the office on follow-up examination two weeks postoperatively. In 10-X% of all patients undergoing postoperative T-tube cholangiography, the examination will be abnormal. There may be failure to visualize all portions of the tree, or inadequate passage of dye into the duodenum, as well as filling defects which could represent a retained calculus. The filling defects may be 763

due to an air bubble, a blood clot, a tumor or a mucosal fold. The T-tube should be left open to drain if the examination is abnormal and the examination repeated in 24 to 48 hours. Noncalculous material may disappear within 24 to 48 hours or its appearance change so that the possibility of a retained stone can be eliminated. Management of retained stones will be discussed later. Pitt and associates evaluated the need for antibiotic coverage for gytients undergoing postoperative T-tube cholangiograEighty-three patients, most of whom had positive bile pb. cultures, did not receive antibiotics. Routine preoperative and postoperative blood cultures disclosed that nine developed a bacteremia after cholangiography, with organisms identical to those in the bile. All, however, recovered without further complications. They concluded that only the very poor risk patients and individuals who have evidence of cholangitis preoperatively should be given prophylactic antibiotics. It would be presumed that patients with cholangitis would be under treatment with antibiotics and that cholangiography would be obtained in those patients only when absolutely necessary. Thus, we agree that the asymptomatic patient undergoing routine cholangiography does not require antibiotic coverage. Following the assurance of a normal biliary tree on the postoperative cholangiogram, the timing of removal of the T-tube is the subject of some difference of opinion. The author prefers to remove the T-tube on the fourteenth day. By this time there is a well-established tract and the removal of the tube will not cause its disruption. During the last 35 years such a complication has not occurred in the author’s experience. Other surgeons, however, have elected to remove the T-tube immediately after obtaining a normal cholangiogram, and, whereas this can be done safely in most instances, bile peritonitis has resulted. COMPLICATIONS OF SURGICAL CHOLEDOCHOLITHIASIS

MANAGEMENT

OF

COMPLICATIONS ASSOCIATED WITH THE USE OF T-TUBES

OBsTRucTIoN.-Tubes may become occluded with blood clots or encrustation of the tube. Fresh blood clots may be removed by gentle irrigation with normal saline solution. Unless hemobilia is severe, this is a temporary problem. The function of Ttubes must be monitored, however, because occlusion of the Ttube may result in occlusion of the common bile duct, since the size of the tube often is very similar to the total diameter of the duct. If a tube is left in place for a prolonged period, for example in the management of a retained stone, encrustation with debris may occur and ultimately the tube may completely occlude. I recommend daily irrigation with sterile saline to flush out such 764

encrustation if long-term patency of the tube is desired. If encrustation occurs, passage of catheters through the T-tube under radiographic control may help to maintain tube patency. An alternative approach is removal of the T-tube and insertion of a straight catheter through the sinus tract. DIFFICULTY IN REMOVING THE T-TUBE.-& the time of placement of the T-tube, it is common practice to excise a portion of the tube immediately opposite the T arm to allow easy collapse of the two arms at the time of removal of the tube. If this is not done, removal of a very large tube may be difficult. Difficulty may also occur because a suture was passed through the tube at the time the duct was closed. If nonabsorbable suture is used, reoperation may be necessary. If catgut is used, however, the suture will dissolve, after which the tube can be removed easily. PREMATURE DISLODGMENT OF THE TUBE.-When T-tubes are placed, they must be securely fastened. They should be securely sewn to the skin, but in addition, there should be sufficient slack in the tube and its connecting tubing to allow it to be taped in place so that if any inadvertent tension occurs, it will affect only the connecting tubing and not dislodge the T-tube. On rare occasions, despite these precautions, the tube may become dislodged. This is potentially a serious, even fatal, complication, if bile peritonitis or subphrenic abscess results. If Penrose drains are still in place, and the tube is no longer necessary, observation is indicated. Reoperation will be required for replacement of the T-tube drainage and treatment of the infection if signs of bile peritonitis develop. When a tube becomes dislodged in the late postoperative period, insertion of a straight catheter through the well-established tract is usually possible. BILIARY FISTULA FOLLOWING CHoLEDOCHoTOMY.-Removal of the T-tube always creates a temporary biliary-cutaneous fistula. The healing process is such, however, that rapid closure normally occurs, and the bile leaks for a period of only a few hours to two or three days. This is not usually called a fistula. When drainage occurs for longer periods, the diagnosis of fistula is warranted. The usual cause of a fistula is obstruction of the distal common duct due to retained stone, tumor, stricture, or stenosis in the region of the sphincter of Oddi. A sinogram should be performed to determine the presence or absence of obstruction and whether or not additional drainage is necessary (Fig 8). Although the development of a fistula through the T-tube tract is an uncommon complication of biliary tract surgery in the absence of distal obstruction, it does occur. On rare occasions large volumes of bile drain from the T-tube tract, even though cholangiography reveals normal flow of dye into the duodenum. The precise reasons for such fistulas are not clear. The only ones which have been observed by the author occurred in elderly, 765

Fig I.-Sinogram in a patient with a biliary fistula. subhepatic space which connects with the biliary tract. well filled. Reoperation was necessary.

There is a large cavity in the The proximal biliary ducts are

somewhat debilitated individuals, and it must be presumed that the capacity to heal the tract was impaired, though no measurable defect was found. Conservative expectant treatment should be used. A bag should be placed for collection of the drainage from the fistula and the patient should be encouraged to eat a normal diet, ingesting sufficient quantities to compensate for the measured fluid and electrolyte loss. Even in the presence of a biliary fistula of this type, sufficient bile will usually enter the gastrointestinal tract to allow satisfactory digestion and absorption of orally ingested foods. If not, the collected bile can be refed, diluted with grape juice or other liquids which disguise both the color and taste of this bitter fluid. In this manner: the patient can, if necessary, be treated at home without requiring special intravenous therapy. The author has never observed a biliary fistula of this type which did not close spontaneously, if not complicated by infection. SUBHEPATIC ABSCESS

This is, fortunately, a relatively rare complication, because most surgeons provide adequate postoperative drainage.“s If drainage is inadequate, however, or is not employed, a collection of bile or blood in the subhepatic space may lead to abscess for766

mation.‘@ When the classic findings of fever, right upper quadrant tenderness, and a palpable mass are present, the diagnosis is easy, but these typical findings are often missing. This lesion often is manifested initially by fever only, without impressive abdominal symptoms or physical abnormalities. Sonography provides a high degree of accuracy in the diagnosis of fluid collections. Computerized tomography and radioactive gallium scans may be helpful in obscure cases. Blood cultures should also be drawn, as septicemia may develop. Septicemia will influence the length of antibiotic administration. In the absence of septicemia, drainage and antibiotic administration usually results in rapid improvement. Untreated abscesses, and particularly those complicated by septicemia, may end fatally. PERITONITIS

Although perihepatic abscess is the most common infection following biliary surgery, generalized peritonitis will occur when there is contamination of the free peritoneal cavity. Peritonitis may be due to the presence of pure bile from leakage of a primarily closed common duct, from slippage of a ligature on the cystic duct when cholecystectomy has been performed, and as a result of premature removal of the T-tube. Pure, uninfected bile in the peritoneal cavity may accumulate in relatively large quantities with few local or systemic symptoms. Bile peritonitis has been considered a rapidly lethal disease, but such is not the usual case in uninfected bile. The exact pathophysiology leading to shock in bile peritonitis in the absence of septicemia has not been fully explained. When secondary infection ensues, however, there may be rapid development of shock, and death may occur. The usual clinical picture is that of slowly increasing abdominal discomfort. In some patients, the symptoms may develop so slowly that two or three days may pass and abdominal distention due to the collection of fluid may be the first actual indication of difficulty. If the diagnosis is insecure, peritoneal tap will reveal the presence of bile. The aspirated material should be submitted for culture and sensitivity, and immediate operation performed to clean the peritoneal cavity and to take steps to prevent the continued passage of bile into the peritoneum, if necessary. If the cystic duct is leaking, it should be ligated. If there has been leakage from primary closure of the bile duct, a T-tube should be placed, closing the incision around the T-tube and the area drained. Simple reclosure of the duct will almost always fail. If the T-tube was removed too soon, it should be replaced and proper drainage established. The general peritoneal cavity, having been thoroughly cleaned, does not need drainage as long as there are no specific loculi of pus, but ade767

quate drainage of the area from which the leakage occurred is essential. The other cause of peritonitis following common duct surgery is leakage from a duodenal incision in patients in whom a sphincteroplasty or choledochoduodenostomy has been performed. Symptoms typically occur as soon as the gastrointestinal contents reach the peritoneal cavity, for the gastric acid, activated pancreatic juice and bile produce an active chemical peritonitis which will be followed by bacterial peritonitis if operation is not performed promptly. The technical procedures to be utilized require mature judgment. The defect in the duodenum should not simply be repaired, for breakdown of such repairs is common. Repair may be established by an onlay patch of jejunum, or by an anastomosis between the area of the incision and the jejunum. Further protection may be obtained by closing the pylorus and performing a gastrojejunostomy to divert gastric contents. Other techniques of diverticularization have been reported. In selected cases the fistulous defect is closed around a tube to aspirate duodenal contents, creating a Witzel tunnel to prevent leakage around the catheter. Under all circumstances, the peritoneal cavity should be cleaned of all foreign material and, in view of the fact that infection can be anticipated, final irrigation with an antibiotic solution is recommended. The area of the duodenal repair should be well drained, irrespective of the technique used. HEMORRHAGE

Hemorrhage may complicate surgery of the common bile duct, either intraoperatively or in the postoperative period. Identification of the common duct in its usual position is not difficult. Often the duct can be visualized even before the peritoneum of the hepatoduodenal ligament is incised. When there has been significant inflammation and scarring, and particularly when there has been previous cholecystectomy, however, the many adhesions and fibrosis in the porta hepatis may make identification of the common duct quite difficult. The possibility of injury to an aberrant artery, the hepatic artery or portal vein exists. Dissection must proceed cautiously, therefore, until the common duct is identified and confirmation of the duct is obtained by needle aspiration of bile. If, during the dissection, a minor tributary of the hepatic artery or the stump of the cystic artery is injured, a simple ligature will suffice. On the other hand, if the common hepatic artery or an aberrant right hepatic artery originating from the aorta or superior mesenteric artery is injured, repair should be undertaken. Repair can be accomplished with the use of vascular clamps above and below the area of injury and the placement of vascular sutures to close the defect. Even total transection of an artery of this size can be 768

appropriately repaired. Temporary occlusion of the arterial supply to the liver is safe during the time required for the repair. As noted previously, the portal vein may be injured. If promptly recognized, repair is readily accomplished. A second source of hemorrhage during the intraoperative period is from the biliary duct. An acutely inflamed duct may become friable and vascular, and the instrumentation necessary for removal of intraductal stones may be sufficiently traumatic to cause bleeding. At times the bleeding is alarming, though mucosal bleeding will almost always stop with application of pressure, including temporary packing of the ductal system. When hemorrhage occurs from the ductal system, however, the possibility that one is dealing with an intraductal tumor, rather than an inflamed duct must be considered, and the specific bleeding point should be identified. Fortunately, with choledochoscopy, direct inspection of the biliary tract is now possible and should such a lesion be found, appropriate surgical treatment is indicated. A third cause of bleeding during the operative period is a disorder of coagulation. The most common abnormality associated with jaundice is prothrombin deficiency due to failure of absorption of vitamin K. Thus, 50 years ago, intraoperative bleeding due to vitamin K deficiency was quite common in jaundiced patients. Death due to hemorrhage from this cause is virtually nonexistent today. All patients with jaundice should have evaluation of the clotting mechanism in the preoperative period and correction of any deficiencies should occur prior to the time of operation. If vitamin K is not administered prophylactically, bleeding can still occur due to coagulation disorders in the postoperative period, despite normal preoperative coagulation studies. I have seen one such case recently. A patient with common duct stones had a serum bilirubin concentration of only 4 mg % and the elevation had been present for only a few days preoperatively. Coagulation studies were within normal limits, and it was deemed that no vitamin K deficiency existed. On the fourth postoperative day, however, severe intra-abdominal hemorrhage occurred. At this time, coagulation tests were abnormal and typical of vitamin K deficiency. There was an immediate response to appropriate administration of vitamin K and blood transfusions, but reoperation was necessary as well. It is obvious, in retrospect, that this complication could have been prevented by prophylactic administration of vitamin K, and illustrates the fact that the presence of normal coagulation studies in the preoperative period does not exclude the possibility that a deficiency will become apparent within the next few days. In the postoperative period, bleeding may occur along the drain tracts because of an unrecognized technical error, slippage of vascular ligatures, or bleeding from a duodenotomy suture 769

line. Reoperation and control of hemorrhage by appropriate sutures and ligatures will be necessary. When bleeding occurs from the drain tract, one must always consider the possibility that the bleeding is occurring from the abdominal wall, rather than from within the abdomen. Each time a stab wound is made in the abdominal wall, careful attention to hemostasis is important. The author has treated patients in whom serious postoperative bleeding occurred from a subcutaneous or a muscle vessel in the abdominal wall. If this possibility is considered, control of this type of hemorrhage may be accomplished without requiring a major operation. The stab wound incision may be extended under local anesthesia for adequate exposure, clamping and ligature of the bleeding vessel. Bleeding from the gastrointestinal tract is an uncommon complication of surgical treatment of choledocholithiasis, but may occur from a number of areas. Bleeding may be mild or may be severe enough to require surgical intervention. It is beyond the scope of this discussion to describe the diagnosis and management of upper gastrointestinal hemorrhage in detail. The lesions to be considered are an unsuspected ulcer, hemorrhagic gastritis or portal hypertension if the patient has concomitant hepatic disease or has developed biliary cirrhosis secondary to the bile duct obstruction. Endoscopic examination for positive diagnosis of the source of bleeding is indicated, and appropriate measures taken, depending upon the specific lesion. Postoperative hemobilia is rare. The presence of hemobilia is readily detected, as the blood will be discharged through the Ttube. Hemobilia following biliary tract surgery is usually minor and stops spontaneously. Should hemobilia continue, cholangiography and/or arteriography should be performed to determine the site of the hemorrhage. The treatment required will depend upon the cause of the bleeding. Hemobilia of such magnitude that reoperation is required could occur, but the author has never encountered this problem, and this complication is not mentioned in a number of articles dealin with postoperative complications of biliary tract surgery.737 74SB25 POSTOPERATIVE PANCREATITIS Pancreatitis occurs in the postoperative period following many operations and the exact pathogenesis is not known. Two operations following which it most frequently occurs, however, are gastrectomy and common duct exploration.g4 Howard, in a study of serum amylase concentrations after biliary procedures, found an elevation in 9% of patients undergoing simple cholecystectomy, but in 29% of patients undergoing exploration of the common bile duct. In a review of the literature, 75 patients were found who developed clinical acute pancreatitis following com770

mon duct exploration and 62 of these patients died.g1’ lg2 Thus, this has been a highly fatal disease. Of particular significance in their study was the fact that 17 of the patients had developed pancreatitis after insertion of the long arm T-tube and in this group, the mortality had been 94%.‘i As noted elsewhere, Cattel, who advocated the use of the long arm T-tube, did not find an increased incidence of postoperative pancreatitis in his patients. The initial treatment of such patients is conservative, but if the clinical features of hemorrhagic pancreatitis develop as evidenced by a Grey-Turner’s sign, Cullen’s sign, or the presence of bloody ascitic fluid, operative intervention with drainage and debridement of necrotic pancreas is indicated. JAUNDICE

The appearance of jaundice following operations on the common bile duct may be due to any of the known causes and requires the same type of evaluation as would be necessary in a patient developing jaundice spontaneously, though it is probable that the jaundice is related specifically to the operation or to circumstances surrounding the operative procedure. It is beyond the scope of this paper to discuss all of the possible causes of jaundice, and only those which may be directly related to the operation will be mentioned. HEMOLYZED RLooD.-Some elevation of serum bilirubin concentration is often seen in patients requiring multiple transfusions. This benign condition results from hemolysis of stored red cells in the transfused units. The degree of hemolysis will vary with the method and length of storage prior to administration. Although in most instances, the serum bilirubin concentration does not rise more than 2 mg % to 4 mg %, the author has observed serum bilirubin levels as high as 10 mg % on this basis. TRANSFUSION REACTION.-The tion must always be considered jaundice immediately following been administered. Although the is much less today with current still occurs.

possibility of transfusion reacin the patient who develops an operation when blood has incidence of this complication blood banking techniques, it

DRUG TOXICITY.-The dangers of hepatic toxicity with halothane anesthesia are well known and have been described extensively, including the danger with repeated administrations. The jaundice usually appears from several days to two weeks postoperatively. In many patients the picture is that of fulminating hepatic necrosis and rapid death. The serum enzyme levels are usually significantly elevated before death occurs. Although halothane toxicity is emphasized because of its hep771

atotoxicity, dysfunction, jaundice.

particularly in patients with preoperative hepatic there are many drugs that can cause cholestatic

BILIARY TRACT oBsTRuCTIoN.-&ones.-Following exploration of the common bile duct for calculous disease, the biliary tract should be normal, for intraoperative cholangiography is performed at the end of the procedure. As will be discussed in more detail later, however, some stones may be retained, despite a normal cholangiogram, and may cause common duct obstruction. When an obstructing stone remains in the distal common duct, jaundice should not occur as long as the T-tube is patent and draining. This diagnosis must be considered if jaundice appears after clamping the T-tube or after the T-tube is removed.

Carcilzoma.-Carcinoma of the pancreas, the ampulla of Vater or the common bile duct may be missed at the time of operation. Gallstones are present in approximately 30% of patients who have carcinoma of the pancreas. Consequently, it is not rare to have coexisting common duct stones and a carcinoma. This possibility must be kept in mind at the time of exploration, and choledochoscopy is particularly valuable, for a number of carcinomas have been overlooked in the past, despite intraoperative cholangiography. When an obstructing lesion is found postoperatively, careful evaluation of its pathology must be made and appropriate therapy instituted. Stricture.-Stricture of the common bile duct resulting from choledochotomy is practically nonexistent. In the author’s experience, there has never been a stricture at the site of choledochotomy and T-tube drainage in a patient having a common duct with a diameter of six millimeters or more. Exploration of the common duct with a diameter of less than three millimeters, however, is fraught with hazard. Even the repair itself may reduce the size of the lumen significantly, and the inflammatory reaction secondary to the T-tube may lead to stricture formation. Furthermore, when the duct is small, it is difficult to place a Ttube with a lumen of sufficient size to obtain good drainage. Ducts of this size, therefore, should be opened only under very compelling circumstances. Currently, with the availability of endoscopic retrograde extraction of stones, it is possible that this technique is safer in this highly selected and unusual group of patients than a formal choledochotomy, though the author has not had occasion to utilize the procedure for this reason. Injury to the common duct unrelated to the choledochotomy incision can occur in patients undergoing common duct exploration. The most common injury actually occurs during the removal of the gallbladder, rather than during the exploration of the common duct. In the report by Smith and associates, an injury to the common duct occurred six times in 316 cases. The cause of common duct injury is a technical failure of properly 772

identifying the duct. The author is aware of at least two instances in which the common duct was totally transected. Fortunately, it was recognized and repair accomplished, and stricture did not occur. In another patient, however, the author treated a stricture which had developed secondary to damage of the common duct at the time of the original operation when sutures were inadvertently placed around the common duct in an attempt to control severe hemorrhage. Although the damage to the duct was recognized during the initial operation, sufficient injury had occurred that stricture developed and multiple operative procedures were subsequently required. Another injury to the common duct which may lead to stricture formation is the creation of a false passage during instrumentation of the distal duct. This injury is more likely to result in postoperative pancreatitis if the pancreas has been injured, or in the development of an abscess or a fistula than a stricture, but all of these complications have been recorded. If a false passage is suspected, immediate cholangiography and/or choledochoscopy should be performed to document the presence or absence of the false passage. Depending upon the location, the false passage may be repaired or it may be splinted with a long T-tube which goes over the area of the injury. Drainage of the area of injury should be accomplished. Antibiotic administration should be continued in the postoperative period. The diagnosis of stricture in the late postoperative period is made on the basis of appropriate laboratory and roentgenographic studies. This is the most serious late complication of common duct surgery, usually due to a technical error, which prior to the antibiotic era was associated with a high five-year mortality rate. Currently, most strictures can be successfully repaired, and death from recurrent infection usually can be prevented with antibiotic therapy. Nevertheless, some of these patients will eventually die, and a significant number will have morbidity due to recurrent stricture, the need for repeated operations and the treatment of recurrent attacks of ascending cholangitis. HEPATIC FAILURE.-AS noted elsewhere, the presence of cirrhosis is a high risk factor in patients requiring biliary tract operations, and hepatic failure may occur in the postoperative period, even in the absence of any specific agents damaging the liver. The use of halothane or hepatotoxic drugs is contraindicated in such patients. If severe hemorrhage and shock develops during the operation, the possibility of hepatic failure increases. The diagnosis of cirrhosis will easily be made at the time of operation and biopsy confirmation for histologic evaluation of the status of the liver should be undertaken in such patients. Even though the possibility that the jaundice is resulting from the primary disease is high, the other causes of jaundice listed here must also be excluded. 773

VIRAL HEPATITIS-When jaundice occurs in the late postoperative period following common duct exploration, viral hepatitis must be seriously considered in the differential diagnosis, if transfusions were administered. Hepatitis B has been reduced by careful screening of transfused blood for this antigen. Non Anon B hepatitis still occurs in a significant number of patients. Diagnosis is usually easily made on the basis of history and physical examinations and the usual laboratory examinations. DRUG TOXICITY Many older patients are receiving multiple drugs before operations, and many drugs are administered in the treatment of choledocholithiasis. When any unexpected abnormality occurs, review of all drug administration is an essential part of the evaluation process. In addition to hepatotoxic drugs mentioned above, common problems and typical drugs include electrolyte imbalance (carbenicillin), fever (penicillin), skin eruptions (penicillin), renal failure (aminoglycosides), ototoxicity (aminoglycosides), and bone marrow depression (Chloromycetin, cephalosporins). FISTULAS Biliary fistula from the choledochotomy incision has been previously mentioned. Biliary fistula may also occur following hepatic resection. Although many close promptly, prolonged biliary drainage and abscess formation related to the fistulous tract are potential hazards. Even under these circumstances, adequate drainage and appropriate antibiotic therapy will usually result in closure without requiring operative intervention. The most serious fistula is a lateral duodenal fistula from failure of healing of a duodenotomy incision for extraction of stones in the distal duct or for sphincteroplasty. If there is adequate drainage and no infection ensues, a trial of conservative therapy with hyperalimentation is the initial treatment of choice. For those fistulas which show no signs of closure within three to four weeks, the proper approach requires mature judgment. Under appropriate circumstances, occlusion of the fistulous tract with bubble gum may be successful. In other patients operative intervention will be necessary. The procedures which have been used include: (1) primary closure; (2) application of a patch made from jejunum; (3) an onlay patch of jejunum; (4) primary closure protected by an onlay patch of jejunum; (5) duodenojejunostomy; (6) closure around a catheter with creation of a Witzel tunnel; (7) pancreatoduodenectomy; and (8) protection of either type of closure by diverticularization. Two types have been described. One includes gastric resection and closure of the duodenal stump. The other consists of occlusion of the pylorus and gastrojejunos774

Fig 9.-Left, a drawing to demonstrate a complicated problem with fistulas following common duct surgery. This patient developed a biliary fistula around a T-tube which had been inserted through the repair of the common duct, as well as a fistula from the duodenotomy incision made to explore the distal end of the common duct. Right, the common duct and duodenum were both repaired. The T-tube was brought out through a separate incision in the common duct. The repair of the duodenum was protected by closure of the pylorus and performance of a gastrojejunostomy with a double lumen tube inserted through a Witzel tunnel with one lumen used for aspiration of the stomach and the other used for feeding into the jejunum well distal to the suture lines in the second portion of the duodenum.

tomy. Most duodenal fistulas treated by the author have not been complications of treatment of choledocholithiasis, but the principles are the same regardless of the cause. The author has used most of these techniques except pancreatoduodenectomy in the treatment of lateral duodenal fistulas (Fig 9). Twenty years ago the mortality rates for treatment of lateral duodenal fistulas ranged from 50 to 75%. Current techniques have resulted in significant reductions in the mortality rates, but lateral duodenal fistula remains a potentially lethal complication. CAUSE OF DEATH

McSherry and Glenn studied the cause of death following surgery for benign biliary tract disease in 11,808 patients. The mortality rate in patients having cholecystectomy alone was only 0.5%, while the mortality rate in patients having choledochotomy plus cholecystectomy or cholecystostomy was 3.5%. Cardiovascular disease was the most common cause of death in the 207 patients who died (Table 7).125 In most series of patients having 775

TABLE PATIENTS

7.-CAUSE

OFDEATHIN

207

OPERATED ON FOR NONMALIGNANT BILIARY TRACT DISEASE* CAUSE

Cardiovascular Hepatobiliary Intra-abdominal Infection Pulmonary Renal Miscellaneous

NUMBER

(extrahepatic)

*From McSherry

60 57 31 20 17 11 11

C.K., Glenn F.lz5

operation on the common bile duct, however, direct complications of the disease process or complications of the operation constitute the major causes of death. In our own series of 288 patients, sepsis in patients with cholangitis accounted for four of the seven deaths, and in an earlier study recorded by Colcock and McManus, complications related to the basic disease process or operation accounted for five of eight deaths.40

RESULTS

OF OPERATION

RETAINED

OR RECURRENT

CALCULI

The majority of patients undergoing operations on the extrahepatic biliary tree are relieved of their symptoms. In patients having negative explorations of the common bile duct, the mortality rate is low. We have had no deaths in this group in the past eight years. The incidence of undiscovered stones is also low, ranging from O-2% in reported series. Even in this group, however, postoperative cholangiography is important, as an occasional overlooked stone will be found. The use of all techniques described has resulted in a decrease in the incidence of retained stones in patients with positive findings on choledochotomy as well, but most authors still report incidences of 4-lo%, including those stones identified at the initial operation but not removed and those found only in the postoperative period. Secondary operations constituted 4.7% of all biliary operations in a review of 5,086gatients undergoing operations on the extrahepatic biliary tract. Of particular interest is the fact that 20 (7.6%) of 264 secondary operations were for tumor not previously diagnosed, emphasizing, again, the importance of complete evaluation of the biliary system whenever operation is performed, irrespective of the presence of stones. The most common cause of recurrent symptoms, however, is retained or recurrent common duct stones. 57, 83, ” In a review by Bordley and White, the incidence of recurrent or retained stones as the cause for reoperation var776

ied from 35-49% among the references which these authors collected from the older literature.28 In their current series of 340 cases, this cause had been reduced to 27%, although it still accounted for the highest percentage for any single indication. A common nonoperative approach to retained calculi identified in the early postoperative period has been simple observation, hoping for spontaneous passage of the stone. Tubes have been left in for periods up to six months, and in many patients spontaneous passage has occurred. The incidence of spontaneous passage, however, is not well documented. Today, active treatment should be instituted, for a variety of techni ues are now available for removal of retained stones.55’ ‘6 io2, l12 FLUSHING AND DIssoLuTIoN.-Attempts to flush stones from the common duct or to dissolve residual stones have been reported for the past 90 years.16’ The simplest maneuver is flushing with saline or water. In 1945, Goldman and associates reported the use of large volumes (l,OOO-1,500 cc) of solution G as a continuous drip with the disappearance of some stones within 24 hours of treatment.7g Lamis, Letton and Wilson recommended removal of the T-tube and placement of a Coude catheter through the T-tube tract for the purpose of flushing, while MacDonald, in 1950, reported the development of a two-way Ttube containing a channel for introduction of fluid, and another channel for drainage.io4, ‘13 He reported the successful elimination of stones using irrigation with water. Most authors, however, have simply irrigated through the T-tube, and some have advocated the use of agents to relax the sphincter. Harris and Marcus have been credited with the first use of an intraductal topical anesthetic as a sphincter relaxant to aid in removal of persistent calculi.85 They used a 1:500 solution of Nupercaine. A variety of other agents has been used, including glyceryl trinitrate, amyl nitrite and similar compounds. Catt and associates administered a dose of propantheline bromide and flushed the Ttube with one liter of normal saline containing 40 ml of lignoCaine, thus combining flushing with sphincter relaxation.33 The solution was allowed to run as rapidly as possible. This procedure was performed multiple times in several of their patients. One patient received 13 treatments over a period of 53 days. The biliary tract was cleared of stones in six of ten patients treated, and one of the failures was due to inadvertent removal of the Ttube. The most potent agent for dissolution of cholesterol gallstones in our experience, as well as that of many others, is chloroform. In the laboratory, cholesterol stones placed in chloroform will often undergo complete dissolution within a half hour without agitation or other mechanical activity. Chloroform was used in humans in the past, and successful dissolution of stones was reported.‘l’ 22 It never received widespread use, however, because 777

of the toxic effects. In some individuals, anesthesia was produced and in others, severe damage to the ductal mucosa resulted. Best and associates credit Walker with the first report of the use of ether, which was injected into a cholecystostomy sinus in 1891. He was successful in removing an impacted cystic duct stone by this procedure.22 Pribram was able to demonstrate that ether could dissolve stones in a test tube and by 1947 reported 51 human cases treated without a failure.155 Best, Rasmussen and Wilson reviewed the experience with dissolution of gallstones in 1953.‘l They reported on 73 patients who were subjected to ether or ether-alcohol instillations by themselves or by their “immediate colleagues” with excellent results. The instillation of ether into the common duct was judged to be safe, but a number of precautions was necessary. Following the injection of ether into the body, there is rapid expansion of this volatile liquid which may result in severe pain. It was the belief of some that the effect of ether was due more to expulsion of the stones than to dissolution of the stone, though Pribram believed that sphincter spasm resulted when rapid expansion occurred, which could neutralize the expulsive effect. Thus, the proper use of ether was described as the introduction of small amounts repeated over prolonged periods. Daily instillations for periods up to eleven months was reported. The available literature documents unequivocally that daily instillations of ether or etheralcohol solutions have resulted in nonoperative elimination of retained common duct stones in several hundreds of patients. Best and associates made a classification of agents which might have an effect upon the dissolution of gallstones (Table 8). They performed tests of a large number of agents as single agents and in combination.21’ 2 On the basis of their studies, they proposed a three-day biliary flush regimen for patients known to have a retained common duct stone. The regimen was started seven days postoperatively, immediately following the Ttube cholangiogram. 1. Three-dehydrocholic acid (Decholin) with belladonna tablets after each meal and at bed time for three days. 2. One-half bottle of magnesium citrate (6 oz) each morning before breakfast. 3. Three tablespoonsful of pure cream or olive oil before noon and evening meals each day. 4. One gylceryl trinitrate tablet (l/100 grain) dissolved under the tongue before the evening meal each day. Instillation Technique 1. By attaching syringe to T-tube, attempt to remove bile from tube and duct. 2. On the first and second days of the biliary flush regimen, heat 4 to 5 cc of chloroform to 60 C. (140 F.) and instill immediately into the side arm of the double-lumen T-tube. 778

TABLE

S.-CLASSIFICATION IN DISSOLVING COMMON

OF SOLUTIONS USED DUCT STONES*

1. Fat solvents tested a. Chloroform b. Ether c. Ether-alcohol d. Alcohol 2. Surface tension lowering agents a. Detergent sorethytan (20) mono-oleate (N.N.R.); polysorbate (U.S.P.) (Sorlate) b. Bile salts c. Bile acids d. Dog bile and ox bile 3. Calcium-binding agents a. Tetrasodium ethelenediaminetetra-acetic (Versenes) b. Citrates 4. Naturally occurring fatty acids a. Saturated (1) Capric (2) Caprylic (3) Laurie (4) Myristic (5) Palmitic (6) Stearic b. Unsaturated (1) Linoleic (2) Linolenic (3) Oleic (4) Ricinoleic c. Hydroxy fatty acids (1) Ricinoleic 5. Hydrotropic agents a. Bile salts b. Bile acids c. Dog and ox bile 6. Enzymatic agents (hydrolytic) a. Trypsin (Tryptar) b. Hyaluronidase (Wydase) c. Caroid 7. Dispersing agents a. Lignin sulfonic compound (Marasperse) 8. Miscellaneous a. Strong acids (1) Nitric acid (2) Hydrocholoric acid b. Weak acids (1) Acetic (2) Glacial acetic c. Boiling water *From

Best

R.R.,

Rasmussen

J.A.,

Wilson

acid

C.E.”

779

3. On the third day, slowly instill 5 cc of ethyl ether into the T-tube, releasing pressure or drawing back on plunger to help control intraductal pressure which gives rise to any distress. 4. Glyceryl trinitrate, l/100 grain, is given sublingually five minutes prior to the instillation of ethyl ether. 5. A recheck choledochogram is done several days later and if stones are still present the regimen is repeated 7 to 14 days later. Despite these positive reports, dissolution of gallstones with the use of ether, chloroform or other substances has not gained widespread popularity. The exact reason for this is unknown. Likely explanations include improper use of ether with production of pain, fear of complications and the fact that daily treatments over a prolonged period were unacceptable to surgeons and to patients. Thus, for many years the generally accepted procedure of choice for retained stones was relatively prompt reoperation. Ten years ago, Way and associates conducted new clinical trials of treatment of retained common duct stones with bile salts solutions.201 Although Best and associates had found the bile salts ineffective in their own studies, a great deal of information had accumulated to suggest the possible efficacy of these agents. The most significant observation related to the understanding of the importance of bile salts in deposition of cholesterol in bile. Furthermore, bile salts given orally had been reported to cause disappearance of gallstones. Thus, the decision to reevaluate bile salts was based upon good rationale, and the administration of sodium cholate, 100 millimole solution administered through the T-tube as a constant drip, resulted in disappearance of stones in 12 of 22 patients between 3 and 14 days after the onset of treatment with no serious complications. The undesirable side effects were diarrhea and intestinal colic. Subsequent additional studies confirm these observations and it is now generally agreed that irrigation with sodium cholate solution, as well as other bile salts, can result in dissolution of stones, both in vitro and in vivo.3, 133*148 A number of other solutions have now been studied. Gardner and associates reasoned that heparin would increase the amount of cholesterol which could be maintained in suspension by increasing the surface charge of individual particles. He referred to this as the zeta potential. In 1975, after experimental work in the laboratory, they reported the use of heparin in humans. Twenty-five thousand units of heparin in 250 ml of saline was administered every eight hours as a constant, continuous drip throu@ the T-tube. Treatment was successful in 31 and failed in 12. Hardie and associates found that only 4 of 17 stones treated in vitro with heparinized saline lost weight. Thirteen gained weight. These results were no different from those with 780

physiologic saline.84 When sodium cholate solution was used, however, 24 of 28 stones lost weight and only four gained weight. These studies were extended by Furnival et al. who then studied the effect of a combination of bile salts and heparin upon gallstones, and observed a significant enhancing effect of the dissolution of gallstones by bile salts when heparin was added.65 In laboratory experiments, the best results were obtained with deoxycholic acid and heparin, with a 77% mean weight loss after 10 days. The author has performed laboratory experiments with heparin and has not found it to be effective in dissolution of gallstones under the experimental plan; however, the author has utilized or has been a consultant in the use of heparin for retained common duct stones in a number of patients and has obtained a success rate similar to that reported by Gardner, and similar to the success rate with bile salts as reported by Way and associates. The explanation for this high success rate is not readily apparent. There are those who have contended that it is simply the flushing technique, but the experiments of Gardner and Furnival indicate some solvent effect (Fig 10). The search for even better agents has continued. Igimi et al. report a study of more than 30 perpene compounds and found that d-p-metha-1, &diene, with the generic name of d-Limonene, was found to be superior to others tested.g2 They found this agent to be highly effective in causing dissolution of pure cholesterol or mixed stones containing a high proportion of cholesFig stone. culous

10.-A, postoperative B, following irrigation disease.

cholangiogram with heparin

demonstrating solution the biliary

retained common duct tract is cleared of cal-

781

terol. To use this solution, it was necessary to remove the T-tube and replace it with a recently developed medical catheter made from epichlorohydrine rubber which is chemically resistant to dlimonene. To achieve the highest concentration of the preparation in direct contact with the stones, the tube was directed to the stones using a guide wire. Rather than a constant drip, 20 ml was injected during a 30-minute period and the tube clamped for one or two hours. Side effects included pain and tenderness radiating from the upper abdomen to the anterior chest, nausea and vomiting, and diarrhea. This agent was used in 15 patients, with as few as three and as many as 25 periods of infusion. Stones disappeared in 13 cases. In a number of these patients, from three to five stones were present in the duct, and all were dissolved. Garcia-Romero et al. have studied clofibrate in vitro.@ Thistle and associates reported successful dissolution of stones by mono-octanoin, a new emulsifying agent. In comparing the efficacy of mono-octanoin with sodium cholate as a cholesterol solvent, their studies disclosed two and a half times more cholesterol in mono-octanoin solutions than in the sodium cholate solution. Clinical use of this agent was accompanied by the complete dissolution in three patients and a decrease in stone size and number in three additional patients.lgO,lgl This material, marketed under the name of Capmul 8210, is a commercial solvent and was used in a more extended trial by Mack and associates, with the volumes infused ranging from 242 to 8,967 milliliters, only one patient receiving more than 2,600 milliliters. The treatment period ranged from a minimum of two days to a maximum of 26 days, with a mean of nine days. Among 20 patients studied with a total of 43 stones, 34 stones were completely dissolved and there were only two patients in whom no stones were dissolved.‘15 Seven stones which were not dissolved were subsequently mechanically extracted. Side effects of infusion included: nausea and vomiting, epigastric discomfort and diarrhea which was usually mild and observed early in the course of therapy. The symptoms were easily controlled with antiemetics and/or analgesics or through temporary decrease in the rate of infusion. Almost half of the patients showed some abnormalities of hepatic function tests, with the most significant change occurring in the alkaline phosphatase concentration, but the increase was less than two-fold. One patient had a marked increase in the serum amylase concentration. Pretreatment values of SGOT, bilirubin and cholesterol showed no statistically significant change. The primary approach to dissolution of common duct stones has been direct irrigation of the stone with the solvent. Over the past several years, however, there has been an investigation of the oral administration of bile salts, particularly chenodeoxycholic acid. Doty and associates, in a study in the prairie dog, 782

demonstrated that the effective dose of this drug relates to the amount of cholesterol ingested orally.51 The higher the cholesterol content of the diet, the greater the cholesterol which is secreted in the bile. A cooperative study has now shown effectiveness in humans. This agent will dissolve stones in the gallbladder and in the common bile duct in some patients, but treatment must be given over a period of six months to two years.13 A national study of the effect of oral chenodeT;zcholic acid in the dissolution of gallstones has been reported. Three groups of patients were studied. In group I, 750 milligrams was administered daily for two years; in group II, 350 milligrams was administered daily and group III served as controls. On the basis of cholecystographic studies, some decrease in the size of stones was observed in 40.8% of group I, 23.5% of group II and 11.0% of group III. Complete disappearance of stones, however, occurred in only 13.5%, 5.2%, and, interestingly, O.&S%,respectively. The greatest effect was in women, thin patients and those with small floating stones. This treatment, however, did not affect the incidence of symptoms among the treated group as compared to the controls or the need for cholecystectomy. Bell and Doran investigated another oral agent, Rowachol, a proprietary “essential oil” preparation which is available on prescription in the United Kingdom.i7 Treatment consisted of 1 capsule/l0 kg body weight/day. Among 24 patients with gallstones, four had stones in the common duct. Three of the four patients with duct stones had complete dissolution within three weeks to six months, while the fourth patient had partial dissolution after twelve months. In summary, successful removal of retained stones by flushing with or without sphincter relaxing agents is well documented. Furthermore, injections through the T-tube tract of agents which effectively dissolve gallstones is associated with a success rate exceeding 70%. Chloroform is a dangerous drug and cannot be recommended, but other solutions are sufficiently safe for clinical application and deserve more widespread use (Table 9). The place of oral agents in the management of common duct stones has not been defined. Oral administration of chenodeoxycholic acid results in complete dissolution of stones in only a small percentage of patients. Whether or not patients with stones in the common duct benefit by decreasing the size of stones is unknown. If these agents are used in patients with common duct stones, they should be restricted to the elderly poor risk asymptomatic patient. When symptoms are present, the risk of complications is too high to warrant a two-year trial of conservative treatment. MECHANICAL EXTRACTION.-In addition to flushing techniques and dissolving techniques, mechanical removal is possible when a well-developed T-tube tract is present (Figs 11 and 12).lg8’ 206 783

TABLE

9.-AGENTS DISSOLUTION

REPORTED TO CAUSE OF GALLSTONES

Chloroform Ether Laurie acid (in alcohol) Bile salts and acids Chenodeoxycholic acid Ursodeoxycholic acid Deoxycholic acid Sodium cholate Heparin d-Limonene Clofibrate Mono-Octanoin (Capmul Rowachol

8210)

McBurney and Gardner reported mechanical extraction of a stone by inserting a straight catheter through the T-tube tract, applying suction after the catheter was placed near the stone, and maintaining suction while the stone was withdrawn with Major impetus was given, however, by the work the catheter.“l of Mazzariello who began instrumental extraction of stones from the gallbladder and from the common duct 20 years ago.i2’ In 1978, he reported an experience with extraction of biliary stones in 1,086 patients during a 14-year period.‘lg He reported successful stone extraction in 95.9% of cases, including removal not only through the T-tube tract, but through the stump of the cystic duct, as well as removal of stones from the common duct Fig tract.

784

Il.-The

Dormia

basket

used

for

extraction

of stones

through

the

T-tube

Fig 12.-Postoperative cholangiogram mon duct. These were removed with and the patient had no further difficulty.

revealing two a Dormia basket

residual stones in the comunder radiographic control,

through a cholecystostomy opening. In addition to use of Dormia baskets and Fogarty catheters, Mazzariello has created a variety of instruments, including sounds, stylets, forceps of various angles, and dilating bougies. The tract can be dilated to allow extraction of large stones. When the stone is too large for extraction, fragmentation may be accomplished. Burhenne has fragmented stones simply by applying continuous pressure with the stone trapped in a Dormia basket until it fragments.31 Bean and associates have utilized ultrasound to fragment large stones, and thus aid in extraction. While held in a Dormia basket, the stone was drilled repeatedly with an ultrasonic drill until it shattered into small fragments and spontaneously cleared.15’ 45 The largest experience in North America has been achieved by Burhenne of Vancouver, who, in 1980 recorded a personal experience of 661 patients treated between 1972 and 1979, removing stones through the T-tube sinus. He also reported a 95% success rate.31 There are several points of importance in the use of this technique. 1. Sufficient time must pass to allow the establishment of a firm fibrous tract which will not be disrupted by the manipulation, obviating the danger of bile peritonitis or abscess formation. Five to six weeks usually is sufficient, but Burhenne advocates even a longer period of time if a T-tube smaller than a 14F has been used. 2. Extraction should not be attempted while Penrose drains are in place. The Penrose drains should have been removed at least two weeks before extraction is accomplished. 785

3. Burhenne prefers to remove the T-tube before extraction. Others, however, have left the T-tube in situ if only one stone is to be extracted, passing a Dormia basket through the Ttube arm and extracting the stone and the T-tube at the same time. 4. After trapping the stone, the stone basket is often not closed around the stone, as this may cause fragmentation. Extraction can be accomplished better when the stone is not tightly gripped. 5. Antibiotic administration is recommended for patients with a history of postoperative pancreatitis or difficult intrahepatic stones. Most patients can be treated satisfactorily on an out-patient basis. Hospitalization is recommended only for patients with severe complicating medical problems. While almost three-fourths of patients with retained stones have a single calculus, in Burhenne’s series, 27% had 2 to 10 stones, and 0.5% had more than 10 stones. He has removed as many as 27 intrahepatic stones from one patient in 5 sessions. Burhenne and Peters reported that the placement of a U-tube is particularly helpful if multiple sittings are required for removal of intrahepatic stones.32 The U-tube permits ease of operation from two sides, particularly if stricture dilatation is required before stone removal. When radiographic techniques are unsuccessful, the choledochoscope can be inserted through the T-tube tract to aid in removal. Even stones in the hepatic radicles may be extracted successfully.23, 77, i30 Some authors have used this technique as the primary approach for stone removal through a T-tube tract, but the experience with this procedure is minimal compared to that of the radiologic techniques, which are now in use in most major hospitals. TRANSDUODENAL ENDOSCOPIC PAPILLoToMv.-If residual stones are not diagnosed until after the T-tube has been removed and the tract healed, a method of extraction not requiring laparotom 107 ix9 3$ua;85now been developed, using a duodenoscope. 7 7 Geenen and LoGuidice credit Classen and Demling in Germany, and Kawai and associates in Japan, with the development of endoscopic diathermy sphincterotomy for removal of common bile duct stones.68 This procedure has had widespread use in those countries since 1974, but has been used in the United States only in the past few years. By 1978 Seifert was able to tabulate 955 patients undergoing endoscopic papillotomy in West Germany with a 92% success rate.175 Recently, Geenen and LoGuidice, who reported their own results in 158 patients, reviewed 3,618 patients from 15 gastroenterology centers worldwide. Of these, 3,070 papillotomies or 84.9%, were performed for common duct stones. Interestingly, in 887 cases, 786

the gallbladder was still in situ, and complete correction of biliary tract disease was not attempted.68 These authors were able to clear the bile duct of stones in 88% of patients. Most of the stones passed spontaneously after endoscopic sphincterotomy, while 36% were extracted with a balloon catheter or basket. The procedure is not innocuous.60 Among the 3,618 endoscopic sphincterotomies, hemorrhage occurred in 90 patients. There were 13 deaths in this group. Perforation of the duodenum or bile duct occurred in 40 patients and 14 of these patients died. Other complications included cholangitis, pancreatitis and stone impaction. The overall complication rate was reported as 7% with a mortality rate of 1.4%. Many of the patients with complications required surgical intervention. Allen and associates have recently used endoscopic sphincterotomy preferentially for patients with residual or recurrent common duct stones found in the late postoperative period.4 Thirtyseven patients were so treated with a success rate of 86%. Seven percent had serious complications, but there were no deaths. Although initially they utilized this procedure only in elderly or poor risk patients, they now prefer it in all patients in whom it can be considered safe. In addition to the contraindications listed by Geenen and LoGuidice, they consider it unsafe in patients with perivaterian duodenal diverticula (Table 10). Because of these contraindications, McSherry and Glenn believe that operative intervention is as safe as endoscopic papillotomy, for in their series of 341 patients operated upon for residual or recurrent calculi, there were 30 patients with cholangitis and 22 with pancreatitis. These complicating lesions are considered contraindications to the use of endoscopic papillotomy, and if these cases are excluded, the mortality rate for choledochotomy in their experience was only 1.2$ which is almost identical with that of endoscopic papillotomy. PERCUTANEOUS TRANSHEPATIC EXTRACTION.-Although endoscopic sphincterotomy has developed as the usual approach to patients in whom operative intervention is not desirable, an alternate procedure has been percutaneous transhepatic extraction of common duct stones.56 TABLE

IO.-CONTRAINDICATIONS ENDOSCOPIC PAPILLOTOMY

Coagulation disorders Long stricture Abnormalities of proximal Large stones > 2.5 cm. Acute pancreatitis Duodenal obstruction Perivaterian diverticula

TO

ducts

787

SURGICAL REMovAL.-Operative intervention is the best method of management of retained stones which cannot be dissolved or extracted through the T-tube tract. If mechanical extraction under radiographic control through the T-tube tract has been unsuccessful, the specific difficulties will not likely be solved by other indirect methods. When retained or recurrent stones are discovered in the postoperative period after the T-tube has been removed, there are several alternatives including endoscopic papillotomy, percutaneous transhepatic extraction and operation. The choice of procedure will depend upon many factors, including risk of procedure and the technical problems. Surgery is specifically indicated in those patients with contraindications to endoscopic papillotomy. Also, if patients have multiple stones found in the late postoperative period, and particularly if they have recurrent stones, surgical intervention is indicated for removal of the stones and to perform an operative drainage procedure to decrease the likelihood of further problems. Operative intervention is more reliable than endoscopic techniques for making sure that the duct is freed of calculous material and that the drainage area is adequate. There is a limitation to the size of the sphincterotomy which can be performed with endoscopic sphincterotomy; whereas, if sphincteroplasty is chosen as a surgical drainage procedure, the opening can be made as large as necessary with satisfactory repair so that leakage should not occur. Allen and associates reported an experience with 47 patients treated surgically for retained or recurrent stones after initial biliary tract surgery.4 The median time following initial surgery was six years. Twenty-six of these patients were treated by choledocholithotomy, while in the remaining patients a surgical drainage procedure was performed, including sphincteroplasty in 5, choledochojejunostomy in 6 and choledochoduodenostomy in 8. They recommend a drainage procedure for the following indications: (1) multiple stones in the duct, (2) history of previous choledocholithotomy, (3) marked dilation of the duct, (4) inability to remove all stones, and (5) presence of a ductal stricture. In addition to the experience of McSherry and Glenn other authors report a low mortality rate and a high success rate with surgical treatment. The procedure to be used should be individualized. The author continues to utilize simple stone extraction and T-tube drainage in patients having only one large retained stone which can be easily removed. Lygidakis reported secondary surgical procedures in 116 cases of postcholecystectomy choledocholithiasis. T-tube drainage alone was utilized in only nine patients, with a 90% success rate.lii The one patient with a stone demonstrated postoperatively had successful removal by mechanical extraction. Ninetytwo patients were treated by choledochoduodenostomy with no 788

postoperative complications and no deaths. The results were much less satisfactory in patients who were treated by sphincteroplasty. These patients were chosen primarily because of the impacted stone in the ductal system. There were nine subhepatic abscesses, three patients with bile peritonitis and three patients who had postoperative pancreatitis. Of particular significance is the fact that the only deaths in the entire series occurred in this latter group of patients with postoperative pancreatitis. The overall mortality rate, therefore, was 1.8%. The long term follow-up results were considered satisfactory, as no reoperation for recurrence of symptoms was carried out after either choledochoduodenostomy or sphincteroplasty. Girard and Legros report an experience with 69 patients who underwent 72 common duct reoperations for retained or recurrent choledocholithiasis.70 There were no major complications and no deaths, with minor complications in only six patients (8.3%). Recurrent choledocholithiasis developed in only two (2.9%) of the patients. These authors also advocate a selective approach to the treatment of retained stones. They point out, however, that reoperation has a good success rate, low morbidity and mortality. These data indicate that there are now several options for treatment of retained or recurrent stones. The author’s approach may be summarized as follows: 1. Retained stone with T-tube in place a. Early trial of flushing and dissolution b. Mechanical extraction through T-tube tract, five to six weeks postoperatively, if flushing is unsuccessful c. Surgical intervention if mechanical extraction is unsuccessful 2. Retained or recurrent stones found in late postoperative period a. Endoscopic removal if no contraindications exist b. Surgical removal (1) When endoscopic technique contraindicated (see Table 10) (2) When endoscopic technique is unsuccessful (3) For recurrent stones (4) When multiple stones are present (5) When a drainage procedure is indicated SUMMARY The diagnosis and management of choledocholithiasis has improved greatly in recent years. Newer diagnostic techniques, including ultrasonography, computerized axial tomography, transhepatic cholangiography and endoscopic retrograde cholangiography have been developed. There have been operative improvements, including the use of the Fogarty catheter, choledo789

choscopy and image amplifiers in the operating room for more precise intraoperative cholangiography. Nevertheless, choledocholithiasis remains a major problem. Choledocholithiasis increases the mortality rate of gallstones as compared to mortality rates resulting from stones in the gallbladder only. Furthermore, retained stones still occur in 4 to 10% of patients operated upon in whom stones are found in the common bile duct. The majority of these, however, can now be removed nonoperatively. REFERENCES 1. Acosta J.M., Rossi R., Galli O.M.R., Pelligrini C.A., Skinner D.B.: Early surgery for acute gallstone pancreatitis: Evaluation of a systematic approach. Surgery 83:367, 1978. 2. Adson M.A., Nagorney D.M.: Hepatic resection for intrahepatic ductal stones. Arch. Surg. 117:611, 1982. 3. Allen B.L., Deveney C.W., Way L.W.: Chemical dissolution of bile duct stones. World J. Surg. 2:429, 1978. 4. Allen B., Shapiro H., Way L.W.: Management of recurrent and residual common duct stones. Am. J. Surg. 142:41, 1981. 5. Appleman R.M., Priestley J.T., Gage R.P.: Cholelithiasis and choledocholithiasis: Factors that influence relative incidence. Mayo. Clin. Proc. 39:473, 1964. 6. Aranha G.V., Sontag S.J., Greenlee H.B.: Cholecystectomy in cirrhotic patients: A formidable operation. Am. J. Surg. 14355, 1982. 7. Argyropoulos G.D., Velmachos G., Axenidis B.: Gallstone perforation and obstruction of the duodenal bulb. Arch. Surg. 114:333, 1979. 8. Arner O., Hagberg S., Seldinger M.L.: Percutaneous transhepatic cholangiography: Puncture of dilated and nondilated bile ducts under roentgen television control. Surgery 52:561, 1962. 9. Ashby B.S.: Choledochoscopy. Clin. Gastroenterol. 7:685, 1978. 10. Balasegaram M.: Current practice in hepatobiliary and pancreatic surgery. Aust. N.Z. J. Surg. 48:479, 1978. 11. Barnes J.P., Jr.: Use of the flexible bronchoscope for common duct endoscopy. Presented at the meeting of the Texas Surgical Society, Corpus Christi, Texas, April 6, 1982. 12. Bartlett M.K., Waddell W.R.: Indications for common duct exploration; evaluation in 1,000 cases. N. Engl. J. Med. 258:164, 1958. 13. Bateson M.C., Hopwood D., Bouchier I.A.D.: Effect of gallstone-dissolution therapy on human liver structure. Dig. Dis. 22:293, 1977. 14. Bauer J.J., Salky B.A., Gelernt I.M., Kreel I.: Experience with the flexible fiberoptic choledochoscope. Ann. Surg. 194:161, 1981. 15. Bean W.J., Davies H., Barnes F.: Ultrasonic fragmentation of large residual biliary tract stone. J. Clin. Ultrasound 5:188, 1977. 16. Beargie R.J., Hodgson J.R., Huizenga K.A., Priestley J.T.: Relation of cholangiographic findings after cholecystectomy to clinical and surgical findings. Surg. Gynecol. Obstet. 115:143, 1962. 17. Bell G.D., Doran J.: Gallstone dissolution in man using an essential oil preparation. Br. Med. J. 1:24, 1979. 18. Berci G., Hamlin J.A.: A combined fluoroscopic and endoscopic approach for retrieval of retained stones through the T-tube tract. Surg. Gynecol. Obstet. 153:237, 1981. 19. Berci G., Shore J.M., Hamlin J.A., Morgenstern L.: Operative fluoroscopy and cholangiography. Am. J. Surg. 135:32, 1978. 20. Berlatzky Y., Freund H.: Choledochoduodenostomy in the treatment of benign biliary tract disease. Am. J. Surg. 141:90, 1981. 21. Best R.R., Rasmussen J.A., Wilson C.E.: An evaluation of solutions for fragmentation and dissolution of gallstones and their effect on liver and ductal tissue. Ann. Surg. 138570, 1953. 790

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792

75. 76. 77. 78.

79.

80.

81. 82.

83. 84.

85. 86.

87. 88.

89. 90.

91. 92. 93.

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