- Email: [email protected]
Intraoperative endoscopic evaluation of the bile ducts
lntraoperative
Leslie W. Ottinger, Andrew
MD, Boston,
L. Warshaw,
Marshall K. Bartlett,
Endoscopic
Evaluation of the Bile Ducts
Massachusetts
MD, Boston, MD, Boston,
Massachusetts Massachusetts
stones after common duct exploration are a persistent problem in the management of biliary calculi. Despite enthusiasm for both instrumental extraction through a T tube fistula [I] and dissolution with heparin [2], our experience indicates that most such stones require removal at a second operation. The incidence of retained stones is variously reported at 2 to 20 per cent. At the Massachusetts General Hospital the incidence has remained at about 5 per cent for several decades [3]. This number does not seem much altered by the increasing use of intraoperative cholangiography in recent years. Recent experience with a new rigid choledochoof calculi overlooked by scope * in the detection the usual technics of common duct exploration is the subject of this report. We share the optimism of others t,hat the instrument will prove to be a significant tool in decreasing the incidence of retained stones [4].
Retained
*Manufactured b? the Karl Stow Angrlvs, (‘alifornia.
Endoscop)~
Company,
Los
From the General Surgical Services, Massachusetts General Hospital and the Department of Surgery, Harvard Medical School, Boston, Massachusetts Reprint requests should be addressed to Dr Ottinger, 275 Charles Street, Boston, Massachusetts 02114. Presented at the Fifty-Fourth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 27-29, 1973.
Volume
127,
April
1974
The choledochoscope has additionally proved useful in the management of two other less frequent but equally vexing problems in biliary surgery. One is the removal of hepatic duct stones. Even when their location is known, blind extraction may prove impossible. When an instrument or catheter can be passed into the appropriate duct, the stones are often pushed peripherally. The other problem is the establishment of a precise diagnosis for an obstructing lesion in the distal common duct. In most instances neither the curette nor the biopsy needle gives reliable information, and direct biopsy through the duodenum or blind resection may be necessary. The choledochoscope can be used to precisely direct an inflatable balloon catheter or biopsy forceps, simplifying the handling of both. Method
The instrument is the Storz right-angled scope. (Figure 1.) It combines a fiberoptic
choledocholight. source
wit,h a rigid optical system. Great depth of field eliminates the need for focusing. The wide angle and exceptional clarity of the optical system allow viewing with minimal distention of the ducts. The portion of the choledochoscope that is introduced into the duct measures only 5 by 3 mm in diameter. Confidence in the accuracy and precision of examination was quickly gained by several surgeons, including members of the resident staff.
465
Ottinger, Warshaw, and Bartlett
Results
Figure 1. The Storz choledochoscope, mbnt carrier, and biopsy forceps.
attachable
Over thirty examinations have been conducted by several surgeons. Visualization has been rated excellent in every instance. In only one case was it impossible to introduce the choledochoscope into a common duct that contained stones. This duct would accept only a number 12 French catheter. Unexpected retained stones were found in six patients, not all of whom had had the usual postexploration cholangiogram. Several surgeons, however, had the impression that choledochoscopy was superior to and a substitute for such cholangiograms. In three patients, hepatic duct stones were removed using the scope after other methods had failed. In one patient the stone was initially discovered by choledochoscopy. In four patients, useful evaluation of the nature of an obstructing distal lesion was possible, and satisfactory biopsy specimens were obtained. T tube cholangiography was performed seven to ten days after common duct exploration in twentytwo patients. The others had choledochoenterostomy and suitable tubes for study were not left in place. In a single patient residual stones were visualized. Review of the operative technic gave no clue to the cause of this technical failure. The intraoperative, postexploration T tube cholangiogram also had failed to visualize these stones. Examination with the rigid choledochoscope should be and was quite atraumatic. In the series there were no complications directly attributable to the use of the instrument. There was only one
instru-
An attachable instrument carrier allows introduction of biopsy forceps alongside the choledochoscope. Biopsy specimens are easily obtained under direct vision. In the same way, a Fogarty embolectomy catheter may be directed beyond a stone in the hepatic ducts for extraction PI .’ After full mobilization of the second portion of the duodenum by the Kocher maneuver, the scope is introduced distally through a short choledochotomy incision. Distal placement of this incision facilitates the examination. In most instances the scope may be passed readily into the duodenum. (Figure 2.) Sphincteric stenosis, obstruction of the duct by extrinsic pressure, a stone, or a tumor are generally readily apparent. The scope is then removed and reintroduced into the proximal ductal system. (Figures 3 and 4.) A direct view into the right hepatic duct is gained immediately, and secondary and tertiary branches are usually seen. The choledochoscope must be angled in an anterior direction for looking into the left duct. The rigid construction of the instrument permits this maneuver.
Fig&e
2. with tbe chole@oc@xkopk
I
diiected
Figure 3. Stone lying in the cqmtpon hepatic Figure 4. Bifuyca!iosof
466
the right hepatic
distally,
duodenal
mucosa
is seen beyond
a patulous sphincter.
duct.
duct after removal
of the stone seen in Figure 3.
.
’
.
Endox
MI)~II~~
Illtt,Q,tion
piic3tioni
in
1hr thirty
5Vere postoperativf2
patient~s. upper
Other
com-
gastrointesti-
in one paGent. pneumonia in a second, and late development of a pancreatic abscess in N third. ‘l’he patient with bleeding ultimately died of’unrc~latecl causes. n:rI l~lecbtlin;:
Comments
Almoict all patients with residual stones after hiliary surgery were suspected preoperatively of having common duct or hepatic duct calculi. Failure to remove them was thus a technical rather t,han a judgmental lapse. Commonly missed are stones in the hepat,ic ducts or in the distal, intrapancreatic portion of the common duct. Because the hepatic ducts cannot he palpated, cholangiography is the only commonly used method that is suitable for detection of contained st.ones. In addition to being time,-consuming, this examination, when performed at the operating table, not, infrequently fails to demonstrate such possibly because of superimposition or stones, overdistent ion of ducts, poor quality of films, and overly hurried interpretation by the surgeon. The distal duct may be palpat,ed readily enough, hut calctlli impacted in the region of the ampulla are oft,en obscured by pancreatic tissue and may allow free passage of instruments by and into the duodenum. Hot h extensive mobilization of the duodenum and cholRngiography sometimes fail to detect such a stone. 1n approaching t,he problem of retained stones, we for a time used a flexible fiberoptic choledochoscope for examination of the duct after instrumenl.ation 161. Visualization was variable and often poor. hot h because excessive distention of the duct was needed and because the flexihle instrument was difficult to direct. Confidence in the technic could not he gained and the instrument was ahandoned. In contrast, the St.orz rigid choledochoscope has proved a reliable and valuable addition to the inst,ruments availahle for finding and removing stones in the common or hepatic duct. The ease of use and the excellence of the view obtained led to its quick adoption as a routine part of common duct exploration. It generally came to he considered equal ill value to the cholangiogram in insuring complete removal of’ all calculi. On the basis of the experience reported in this paper we believe this choledorhoscope merits a wide clinical trial.
Volume 127, April 1974
opy of Bile Ducts
Summary
On the basis of c,xperience in o\pr I hirr (‘OXI mon duct explorations, the Star/ rigid c~holedochoscope has proved to be a simplt,. rrliahle. and valuable instrument. Its use is associa~e(I with f’ew, if any, complications. Applications include exam-. nation of proximal and distal ducts lo insure cornplete removal of stones, visualizatiorl and biopsy of’ the sphincter and distal obstructing lesions, and visual introduction of an eml~olect.on~y c.athet er beyond hepatic duct stones for extraction. References 1. Mazzariello R: Review of 220 cases of residual biliary tract calculi without reoperation: an eight year study. Surgery 73: 299, 1973. 2. Gardner B: Experience with the use of intracholedochal heparinized saline for the treatment of retained common duct stones. Ann Surg 177: 240, 1973. 3. Bartlett MK: Retained and recurrent common duct stones. Am Surg 38: 63, 1972. 4. Shore JM, Morgenstern L, Berci G: An improved rigid choledochoscope. Am J Surg 122: 567, 197 1. 5. Warshaw AL, Bartlett MK: A technique for finding and removing stones from intrahepatic bile ducts Am J Surg 127: 353, 1974. 6. Schein CJ: Biliary endoscopy. An appraisal of Its value in biliary lithiasis. Surgery65: 1004, 1969.
Discussion
George R. Dunlop organized presentation
(Worcester, Mass): This is a well of a new invasive method of’ de-
tecting common duct stones. It raises the question of whether this method is better than is routine intraoperative cholangiogram for detecting common duct stones. It is not unusual to be a little overenthusiastic ahout the possibilities of a new instrument, and 1 think there is every reason for enthusiasm with this instrument. The presentation is colored by a few gentle references to the intraoperative cholangiogram, and in defense of’ it I must make a comment or two. In’ referring to the intraoperative cholangiogram, the paper implies that it is time-consuming. If’ time-consuming is five or six minutes, than I must admit t.bat it is time-consuming. The next reference to the cholangiogram states that, “it not infrequently fails to demonstrate stones.” 1Vell. now, what does “not infrequently” mean‘? If it means 5 or 3 per cent, one would have to admit to that. The question now is should it be used instead of the routine intraoperative cholangiogram or should it 1~ used to complement it. I think we all admit that clinically we cannot determine accurately which ducts contain stones. The rulrs we learned in medical school do not always lead to the discovery of the stones. When Dr Catell was alive, he admitted to having generous indications for exploring a
467
Ottinger, Warshaw, and Bartlett
common duct that was at all suspicious. Wi,h the usual clinical indications, about two thirds of the ducts he explored contained no stones. This, I think, has been the experience of most of us. A few years ago Dr Colcock and Dr Bartlett each presented before this Society a series of cases of cholecystectomy. If my memory serves me correctly, they showed that choledochotomy increased the mortality from 0.5 to 1 per cent in the two series. Opening the common duct does add something to the risk, admittedly very little. It does increase hospitalization and cost. What does this add up to? I would say that we have been shown the effectiveness of an excellent new instrument. If we can afford it, we ought to buy it and use it. However, I do not believe that it should be used instead of the routine intraoperative cholangiogram. This x-ray method is the best one currently available to surgeons for detecting stones in the common duct. Once the common duct is opened, it would appear that the best way to detect stones in the open duct is with the use of the choledochoscope. Lester F. Williams, Jr (Boston, Mass): I would like to ask several questions. First, is this series of patients a very selected one? It should be, because six patients had calculi found by this method “after other methods had failed.” This incidence of overlooked stones is too high if this is not a highly selected group. Second, in our pre-
466
sentation, we suggested that biliary obstruction secondary to stones was rather easily diagnosed in most circumstances, whereas high degrees of obstruction secondary to unusual lesions such as carcinoma of the proximal bile ducts were difficult to diagnose. Will this instrument help us in these more involved and unusual cases? Leslie W. Ottinger (closing): It would actually be quite difficult for Dr Dunlop and me to find much on which we could disagree. We do not suggest that the scope should replace standard technics of duct exploration but rather that it should supplement them. We have used intraoperative cholangiography with increasing frequency in recent years. Although it is often rather time-consuming and may at times be misleading, there is no question that it is very helpful in many cases. Six stones in thirty patients does seem to be quite a high incidence. This reflects at least two factors. The early examinations were performed in complicated cases in which reoperation was required for the most part. Also, choledochoscopy was carried out before the intraoperative, postexploration cholangiogram which would have.revealed at least some of the retained stones. In conclusion, we do not know how valuable the instrument will be in the final analysis. At this point, however, it does seem especially useful in finding and removing stones in the hepatic ducts and in evaluating the cause of distal common duct obstruction.
The American Journal of Surgery
Leslie W. Ottinger, Andrew
MD, Boston,
L. Warshaw,
Marshall K. Bartlett,
Endoscopic
Evaluation of the Bile Ducts
Massachusetts
MD, Boston, MD, Boston,
Massachusetts Massachusetts
stones after common duct exploration are a persistent problem in the management of biliary calculi. Despite enthusiasm for both instrumental extraction through a T tube fistula [I] and dissolution with heparin [2], our experience indicates that most such stones require removal at a second operation. The incidence of retained stones is variously reported at 2 to 20 per cent. At the Massachusetts General Hospital the incidence has remained at about 5 per cent for several decades [3]. This number does not seem much altered by the increasing use of intraoperative cholangiography in recent years. Recent experience with a new rigid choledochoof calculi overlooked by scope * in the detection the usual technics of common duct exploration is the subject of this report. We share the optimism of others t,hat the instrument will prove to be a significant tool in decreasing the incidence of retained stones [4].
Retained
*Manufactured b? the Karl Stow Angrlvs, (‘alifornia.
Endoscop)~
Company,
Los
From the General Surgical Services, Massachusetts General Hospital and the Department of Surgery, Harvard Medical School, Boston, Massachusetts Reprint requests should be addressed to Dr Ottinger, 275 Charles Street, Boston, Massachusetts 02114. Presented at the Fifty-Fourth Annual Meeting of the New England Surgical Society, Portsmouth, New Hampshire, September 27-29, 1973.
Volume
127,
April
1974
The choledochoscope has additionally proved useful in the management of two other less frequent but equally vexing problems in biliary surgery. One is the removal of hepatic duct stones. Even when their location is known, blind extraction may prove impossible. When an instrument or catheter can be passed into the appropriate duct, the stones are often pushed peripherally. The other problem is the establishment of a precise diagnosis for an obstructing lesion in the distal common duct. In most instances neither the curette nor the biopsy needle gives reliable information, and direct biopsy through the duodenum or blind resection may be necessary. The choledochoscope can be used to precisely direct an inflatable balloon catheter or biopsy forceps, simplifying the handling of both. Method
The instrument is the Storz right-angled scope. (Figure 1.) It combines a fiberoptic
choledocholight. source
wit,h a rigid optical system. Great depth of field eliminates the need for focusing. The wide angle and exceptional clarity of the optical system allow viewing with minimal distention of the ducts. The portion of the choledochoscope that is introduced into the duct measures only 5 by 3 mm in diameter. Confidence in the accuracy and precision of examination was quickly gained by several surgeons, including members of the resident staff.
465
Ottinger, Warshaw, and Bartlett
Results
Figure 1. The Storz choledochoscope, mbnt carrier, and biopsy forceps.
attachable
Over thirty examinations have been conducted by several surgeons. Visualization has been rated excellent in every instance. In only one case was it impossible to introduce the choledochoscope into a common duct that contained stones. This duct would accept only a number 12 French catheter. Unexpected retained stones were found in six patients, not all of whom had had the usual postexploration cholangiogram. Several surgeons, however, had the impression that choledochoscopy was superior to and a substitute for such cholangiograms. In three patients, hepatic duct stones were removed using the scope after other methods had failed. In one patient the stone was initially discovered by choledochoscopy. In four patients, useful evaluation of the nature of an obstructing distal lesion was possible, and satisfactory biopsy specimens were obtained. T tube cholangiography was performed seven to ten days after common duct exploration in twentytwo patients. The others had choledochoenterostomy and suitable tubes for study were not left in place. In a single patient residual stones were visualized. Review of the operative technic gave no clue to the cause of this technical failure. The intraoperative, postexploration T tube cholangiogram also had failed to visualize these stones. Examination with the rigid choledochoscope should be and was quite atraumatic. In the series there were no complications directly attributable to the use of the instrument. There was only one
instru-
An attachable instrument carrier allows introduction of biopsy forceps alongside the choledochoscope. Biopsy specimens are easily obtained under direct vision. In the same way, a Fogarty embolectomy catheter may be directed beyond a stone in the hepatic ducts for extraction PI .’ After full mobilization of the second portion of the duodenum by the Kocher maneuver, the scope is introduced distally through a short choledochotomy incision. Distal placement of this incision facilitates the examination. In most instances the scope may be passed readily into the duodenum. (Figure 2.) Sphincteric stenosis, obstruction of the duct by extrinsic pressure, a stone, or a tumor are generally readily apparent. The scope is then removed and reintroduced into the proximal ductal system. (Figures 3 and 4.) A direct view into the right hepatic duct is gained immediately, and secondary and tertiary branches are usually seen. The choledochoscope must be angled in an anterior direction for looking into the left duct. The rigid construction of the instrument permits this maneuver.
Fig&e
2. with tbe chole@oc@xkopk
I
diiected
Figure 3. Stone lying in the cqmtpon hepatic Figure 4. Bifuyca!iosof
466
the right hepatic
distally,
duodenal
mucosa
is seen beyond
a patulous sphincter.
duct.
duct after removal
of the stone seen in Figure 3.
.
’
.
Endox
MI)~II~~
Illtt,Q,tion
piic3tioni
in
1hr thirty
5Vere postoperativf2
patient~s. upper
Other
com-
gastrointesti-
in one paGent. pneumonia in a second, and late development of a pancreatic abscess in N third. ‘l’he patient with bleeding ultimately died of’unrc~latecl causes. n:rI l~lecbtlin;:
Comments
Almoict all patients with residual stones after hiliary surgery were suspected preoperatively of having common duct or hepatic duct calculi. Failure to remove them was thus a technical rather t,han a judgmental lapse. Commonly missed are stones in the hepat,ic ducts or in the distal, intrapancreatic portion of the common duct. Because the hepatic ducts cannot he palpated, cholangiography is the only commonly used method that is suitable for detection of contained st.ones. In addition to being time,-consuming, this examination, when performed at the operating table, not, infrequently fails to demonstrate such possibly because of superimposition or stones, overdistent ion of ducts, poor quality of films, and overly hurried interpretation by the surgeon. The distal duct may be palpat,ed readily enough, hut calctlli impacted in the region of the ampulla are oft,en obscured by pancreatic tissue and may allow free passage of instruments by and into the duodenum. Hot h extensive mobilization of the duodenum and cholRngiography sometimes fail to detect such a stone. 1n approaching t,he problem of retained stones, we for a time used a flexible fiberoptic choledochoscope for examination of the duct after instrumenl.ation 161. Visualization was variable and often poor. hot h because excessive distention of the duct was needed and because the flexihle instrument was difficult to direct. Confidence in the technic could not he gained and the instrument was ahandoned. In contrast, the St.orz rigid choledochoscope has proved a reliable and valuable addition to the inst,ruments availahle for finding and removing stones in the common or hepatic duct. The ease of use and the excellence of the view obtained led to its quick adoption as a routine part of common duct exploration. It generally came to he considered equal ill value to the cholangiogram in insuring complete removal of’ all calculi. On the basis of the experience reported in this paper we believe this choledorhoscope merits a wide clinical trial.
Volume 127, April 1974
opy of Bile Ducts
Summary
On the basis of c,xperience in o\pr I hirr (‘OXI mon duct explorations, the Star/ rigid c~holedochoscope has proved to be a simplt,. rrliahle. and valuable instrument. Its use is associa~e(I with f’ew, if any, complications. Applications include exam-. nation of proximal and distal ducts lo insure cornplete removal of stones, visualizatiorl and biopsy of’ the sphincter and distal obstructing lesions, and visual introduction of an eml~olect.on~y c.athet er beyond hepatic duct stones for extraction. References 1. Mazzariello R: Review of 220 cases of residual biliary tract calculi without reoperation: an eight year study. Surgery 73: 299, 1973. 2. Gardner B: Experience with the use of intracholedochal heparinized saline for the treatment of retained common duct stones. Ann Surg 177: 240, 1973. 3. Bartlett MK: Retained and recurrent common duct stones. Am Surg 38: 63, 1972. 4. Shore JM, Morgenstern L, Berci G: An improved rigid choledochoscope. Am J Surg 122: 567, 197 1. 5. Warshaw AL, Bartlett MK: A technique for finding and removing stones from intrahepatic bile ducts Am J Surg 127: 353, 1974. 6. Schein CJ: Biliary endoscopy. An appraisal of Its value in biliary lithiasis. Surgery65: 1004, 1969.
Discussion
George R. Dunlop organized presentation
(Worcester, Mass): This is a well of a new invasive method of’ de-
tecting common duct stones. It raises the question of whether this method is better than is routine intraoperative cholangiogram for detecting common duct stones. It is not unusual to be a little overenthusiastic ahout the possibilities of a new instrument, and 1 think there is every reason for enthusiasm with this instrument. The presentation is colored by a few gentle references to the intraoperative cholangiogram, and in defense of’ it I must make a comment or two. In’ referring to the intraoperative cholangiogram, the paper implies that it is time-consuming. If’ time-consuming is five or six minutes, than I must admit t.bat it is time-consuming. The next reference to the cholangiogram states that, “it not infrequently fails to demonstrate stones.” 1Vell. now, what does “not infrequently” mean‘? If it means 5 or 3 per cent, one would have to admit to that. The question now is should it be used instead of the routine intraoperative cholangiogram or should it 1~ used to complement it. I think we all admit that clinically we cannot determine accurately which ducts contain stones. The rulrs we learned in medical school do not always lead to the discovery of the stones. When Dr Catell was alive, he admitted to having generous indications for exploring a
467
Ottinger, Warshaw, and Bartlett
common duct that was at all suspicious. Wi,h the usual clinical indications, about two thirds of the ducts he explored contained no stones. This, I think, has been the experience of most of us. A few years ago Dr Colcock and Dr Bartlett each presented before this Society a series of cases of cholecystectomy. If my memory serves me correctly, they showed that choledochotomy increased the mortality from 0.5 to 1 per cent in the two series. Opening the common duct does add something to the risk, admittedly very little. It does increase hospitalization and cost. What does this add up to? I would say that we have been shown the effectiveness of an excellent new instrument. If we can afford it, we ought to buy it and use it. However, I do not believe that it should be used instead of the routine intraoperative cholangiogram. This x-ray method is the best one currently available to surgeons for detecting stones in the common duct. Once the common duct is opened, it would appear that the best way to detect stones in the open duct is with the use of the choledochoscope. Lester F. Williams, Jr (Boston, Mass): I would like to ask several questions. First, is this series of patients a very selected one? It should be, because six patients had calculi found by this method “after other methods had failed.” This incidence of overlooked stones is too high if this is not a highly selected group. Second, in our pre-
466
sentation, we suggested that biliary obstruction secondary to stones was rather easily diagnosed in most circumstances, whereas high degrees of obstruction secondary to unusual lesions such as carcinoma of the proximal bile ducts were difficult to diagnose. Will this instrument help us in these more involved and unusual cases? Leslie W. Ottinger (closing): It would actually be quite difficult for Dr Dunlop and me to find much on which we could disagree. We do not suggest that the scope should replace standard technics of duct exploration but rather that it should supplement them. We have used intraoperative cholangiography with increasing frequency in recent years. Although it is often rather time-consuming and may at times be misleading, there is no question that it is very helpful in many cases. Six stones in thirty patients does seem to be quite a high incidence. This reflects at least two factors. The early examinations were performed in complicated cases in which reoperation was required for the most part. Also, choledochoscopy was carried out before the intraoperative, postexploration cholangiogram which would have.revealed at least some of the retained stones. In conclusion, we do not know how valuable the instrument will be in the final analysis. At this point, however, it does seem especially useful in finding and removing stones in the hepatic ducts and in evaluating the cause of distal common duct obstruction.
The American Journal of Surgery