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The problem of retained common duct stones
The
Problem of Retained Duct Stones
Common
N. FREDERICK HICKEN, M.D., A. JAMES MCALLISTER, M.D. AND GLENN WALKER, Salt Lake City, Utah From tbe Surgical Service, University of Utab College of Medicine; and Latter Days Saints Hospital, Salt Lake City, Utah.
NFORTUNATELYthe actuaI accomphshments of surgery often falI short of our hopeful desires. In spite of improved diagnostic faciIities and excehence of surgica1 skiIIs we must often accept defeat, or at Ieast admit temporary faiIures. Such have been our experiences in operations upon the hepatobiliary system. We have been chagrined by our faiIure to open the bile ducts when they contained stones, and embarrassed by our inabiIity to remove a11 of the caIcuIi from the ducts which were explored. The undesirabIe compIication of “residual,” “overIooked” or “missed” intraducta1 stones occurs with annoying frequency. Pribram [2?] reported that 16 to 25 per cent of patients operated upon for choIedochoIithiasis stiI1 harbor intraductal caIcuIi. Smith et al. [27] performed 224 choIecystectomies and choIedochotomies and found that in twenty-four patients (IO per cent) a11 stones had not been removed. Thomson [28] re-expIored the biIe duct of 1o6 patients and was surprised to find that I I .6 per cent stiI1 had residual stones. Likewise, SingIeton and CoIeman [26] performed fortythree choledocholithotomies but failed to remove a11 caIcuIi in three cases, an incidence of g per cent. Buxton and Burk [8] performed leaving residual 190 choIedochoIithotomies, stones in 8.3 per cent. They aIso expIored the biIe duct of 249 patients without finding stones, yet postoperative choIangiograms demonstrated retained stones in 3.6 per cent of their cases. Glenn [lo] foIIowed up IOO patients having cholecystectomies for gaIIstones, in whom the biIe ducts were not expIored, and found that within a ten-year period 4 per cent required secondary operations for residua1 choIedocha1
U
M.D.,
stones. In performing 715 consecutive choIecystectomies for ChoIeIithiasis, we expIored the biIe duct of 232 patients (32.4 per cent); choIedocha1 stones were recovered from 105 patients (48 per cent). In four instances (3.5 per cent) we faiIed to remove a11 intraducta1 stones. Why are not a11 caIcuIi removed from the Iarger biIe ducts during choIedochotomy? In order to answer these questions the records of eIeven IocaI hospitaIs were studied, from which 150 instances of “retained” choIedocha1 stones were found. The primary operations were performed by thirty-eight different surgeons, consisting of residents, occasiona operators and certified surgeons. ResiduaI stones were missed ten times more frequentry by the occasiona operator than by the we11 trained surgeon [12]. There are certain pathoIogica1 conditions associated with choIeIithiasis which seem to prevent the compIete remova of a11 offending caIcuIi: Hepatolitbiasis. Intrahepatic caIcuIi are usuaIIy inaccessibIe and cannot be removed, yet they occur in 7.4 per cent of a11 cases of choIeIithiasis, according to Beer [j], Best [4], and Hicken, McAIIister and CaII [14]. HepatoIithiasis was found in forty-two of our patients by operative choIangiograms, and in none of them were we abIe to remove a11 the stones. (Fig. I.) In twenty-four instances the caIcuIi were found in both Iobes of the Iiver, in tweIve cases they were confined to the Ieft Iobe onIy, and in six to the right Iobe. One patient required four choIedochoIithotomies because the hepatic stones persisted in migrating down into the common duct and producing an obstructive jaundice. The last operation was performed eight years ago and she is enjoying good health in spite of the fact that she stiI1 has many intrahepatic stones. Because the surgeon can seIdom
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FIG. I. A, four stones were removed from the common duct and the sphincter was dilated. The postoperative cholangiogram shows an “ovedooked stone” in the right hepatic duct and obstruction of the ampulla due to pancreatic edema and swelIing. B, seven days Iater the right hepatic stone had migrated to the ampuIIary portion of the common duct. Because of the narrowing of the termina1 portion of the choIedochus, this stone was recovered at a second operation.
obstruct the common duct there is no attendant jaundice; hence the cIinica1 indications for ducta expIoration are absent. Operative choIangiograms afford the best method, for discovering these mispIaced caIcuIi. OccasionaIIy inspissated biIe and “sand” obstruct the cystic duct but are not Iarge enough to be detected by paIpation, hence are often overIooked. Such stones can and do cause symptoms. (Fig. 3.) Impacted Stones. Under certain circumstances gallstones may become impacted in the termina1 portion of the choIedochus where resuIting ducta fibrosis and infIammation intensify their incarceration. If grasping forceps are applied to such a caIcuIus the force necessary to extract the stone may be sufficient to break it into smaI1 pieces. The sharp fragments may be driven into the ducta wall, onIy to produce tissue irritation, and Iater escape into the ducta Iumen. Sometimes these fragments Aoat around in the biIe and cannot be flushed out by ducta irrigations or removed by scoops. These smaI1 sand-Iike particIes form an exceIIent nidus for the formation of new stones. Speed. Another factor which contributes to “retained” choIedocha1 stones is the tendency to rush through operations. It requires time to expose the biIe ducts adequateIy, explore their
IocaIize, Iet aIone remove, Iiver stones this particuIar phase of “retained” caIcuIus seems insoIubIe. Small Stones. Experience indicates that it is diffIcuIt to rid the biIe ducts of biliary sand and smaII caIcuIi. UnIess the stones are of a sufficient mass they do not impart an impact, or produce a “sense of scraping,” when coming in contact with the expIoring scoops, forceps and probes; hence the surgeon is unable to detect their presence. On many occasions we have thought a11 the stones had been removed from the biIe ducts and, on “passing the scoop once more just for good Iuck, ” another eIusive stone roIIed out. Likewise, we have persistentIy and thoroughIy irrigated the biIe duct to be certain that a11 bile-sand had been fIushed into the duodenum and, whiIe talking to the resident, have seen an unexpected stone float out of the ducta incision. SmaII caIcuIi can be missed, as evidenced in Figure 2. Encysted Stones. Sometimes stones become IocuIated in diverticuIar sacs of the biIe ducts and, as they do not encroach on the ducta Iumen, instruments may be passed aIong the ducts without ever coming in contact with caIcuIus. If these stones are smaI1 they cannot be detected by palpation. Because they do not 174
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Common
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3
2
FIG.
2.
Five stones were removed from this common
duct but one small caIcuIus was “missed.”
FIG. 3. Postoperative cholangiogram outlines “overlooked” stones in left hepatic, common hepatic and choledochal ducts. The dilated stump of the cystic duct contains stones.
Just as the ducts were to be explored the anesthetist urged the surgeon to terminate the operation; hence a decompression tube was inserted into the common bile duct and the abdomen was cIosed even though stones were knowingIy Ieft behind. Nine years later she was compelIed to submit to a second operation, and the operative choIangiogram denoted a diIated biIe duct filIed with many stones. Proper preparation of the patient shouId have permitted a11 offending stones to be removed at the primary operation.
Iumen, extract contained calculi, lavage the intrahepatic radicIes and dilate the ampulla of Vater. Additiona time may be needed to perform plastic procedures upon the stenotic ampuIIary orifice. If the patient has been improperIy prepared or if he is a poor operative risk, the surgeon may be unabIe to take the necessary time to perform these corrective procedures. Figure 4 is a choledochogram of a patient who has had three operations for choIedocha1 stones “ reformed ” or “residua1” al1 because the strictured ampulIary segment of the common duct was not diIated at the primary operation. Such stenotic Iesions can be best corrected by transduodena1 ampuIIotomy or hepaticojejunostomy. Patients with ChoIelithiasis are seIdom so acutety III that ampIe time cannot be taken to prepare them for the added trauma of surgery. Even when deaIing with acute ChoIecystitis it is not necessary to perform “middIe of the Figure 3 represents the night ” operations. extrahepatic system of a patient with acute cholecystitis and jaundice. She was rushed to surgery. The gaIIbIadder was removed and the common biIe duct was found to contain stones.
DIAGNOSIS
No one wiI1 contradict the statement that every bile duct which contains stones shouId be opened and thoroughIy expIored. The enigma is, which ducts harbor caIcuIi? UnfortunateIy the conventiona criteria for choIedochotomy are not infallible. For exampIe, the size of the common duct is not an accurate guide for expIoration as many diIated ducts do not contain stones, whiIe norma or smaII-sized ducts may. PaIpation is not infaIIibIe as Buxton and Burk [8] were abIe to paIpate only 48 per cent of the choIedocha1 175
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F~ti. 4. A, seven stones and some biliary sand were removed from the common duct. The postoperative cholangiogram demonstrates a stenosis of the terminal portion of the choledochus. B, eight months Iatcr the patient returned with obstructive jaundice. The operative cholangiogram outlines two large stones and obstruction of the ampuIla. ChoIedochohthotomy and transduodenal ampulIotomy were employed.
the surgeon obtains an accurate radiographic pattern of the entire biIiary system. He has a “ bIueprint ” of the probIems to be soIved. PathoIogic Iesions such as stones, kinks, strictures and neoplasms produce recognizabIe deformities. Anatomic variations in size, shape and position of the biIe duct can be quickIy recognized. This form of examination is not intended to suppIant the conventiona methods for determining the functiona status of the biIe ducts, such as inspection, paIpation and instrumenta1 expIoration, but is rather a vaIuabIe compIementary procedure. Cholangiograms provide additiona information by showing which ducts are norma (hence do not need to be expIored) and designating those which shouId be opened. In 106 choIedocholithotomies we were abIe to paIpate but 52 per cent of the stones which were removed, indicating that 48 per cent of the caIcuIi were Iocated by choIangiograms. It is interesting that in forty-two instances the ChoIangiograms outIined intrahepatic stones which couId not be detected by any other method. This agrees with the experiences of Mehn [zo] who found ten unsuspected stones in I 13 choIangiograms.
stones they removed. This means that 52 per cent of the caIculi were either too smaI1 or Iocated in such a position that they could not be detected by the paIpating fingers. Jaundice is not an accurate indication for choIedochotomy as onIy 60 per cent of our ITO cases exhibited hyperbilirubinemia even though the ducts contained stones. Examination of the statistics from the Iarger surgical centers, where we11 trained surgeons work, indicates that onIy 20 to 50 per cent of the choIedochotomies yieId caIcuIi. In simpIer terms, the conventiona indications for ducta expIoration were misIeading in 50 to 70 per cent of the cases. UnfortunateIy the indications for choledochotomy vary with the enthusiasm and experience of the surgeon, and not unti1 some exact method of diagnosis and IocaIization of intraducta1 stones are avaiIabIe wiIl these errors be minimized. As yet we have no such procedure. Operative Cholangiograpby. Since 1936 we have empIoyed operative and postoperative choIangiography as a routine procedure in more than 1,800 hepatobiIiary operations. By injecting suitabIe contrast media into the gaIIbladder and biIe ducts during the operation, 176
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ied I 2 I patients with ” postchoIecystectomy ” compIaints and were abIe to visuahze the biIe ducts in 105 instances, finding intraductal caIcuIi in eIeven cases (g per cent). InterestingIy they discovered caIcuIi in ducts having a normal diameter or caliber. GIenn [IX] recommends intravenous ChoIangiographic studies of a11 patients having choIedocho1ithotomies at intervals of one, two and three years. He believes it takes time for the smaI1 overlooked caIculi to enlarge sufhcientIy to be recognized by this method. UnfortunateIy such studies cannot be employed in the presence of jaundice, choIangitis, hepatitis, cirrhosis of the Iiver or in criticalfy ill patients; hence their diagnostic usefulness is somewhat Iimited.
Baker [2], Mixter, Hermanson and Segel [21], and Hoerr [ 151 emphasize that operative cholangiograms are not onIy usefuI in determining the presence of intraducta1 stones but also very heIpfu1 in ascertaining which ducts are normal, thus eliminating unnecessary ductal explorations. Like all diagnostic procedures, however, cholangiography has its limitations, is occasiona1Iy misleading and at times absofutelg uninformative, but what radiologic procedure is not, whether it be a urogram, an encephaIogram or an x-ray study of the gastrointestina1 tract. Experience and precision do much to reduce the percentage of errors. Completion Cbolangiograms. Whenever the common biIe duct has been opened and expIored the surgeon is always anxious to know if a11 offending caIcuIi have been removed. Such information can be obtained by injecting the T tube with a suitabIe contrast medium and obtaining a choIedochogram whiIe the abdomen is stiI1 open. Th omson [28] used completion choIangiograms in a11 choledocholithotomies and was compelled to remove the T tubes and re-explore the ducts because of retained caIcuIi in 25 per cent of his cases. We have discovered “overIooked” stones by this method in ten instances, and have removed the T tubes and extracted the eIusive caIcuIi. It is much better to detect the residua1 stone at the primary operation than be compeIIed to subject the patient to a second expIoration. Postoperative Cbolangiograpby. The onIy method for determining whether a11 stones have been removed from the bile ducts is to employ The cIinica1 postoperative choIangiograms. course provides no index as to the compIeteness of the primary choIedochoIithotomy. In more than 80 per cent of our 150 cases the patients were well enough to leave the hospita1, even though it was known that their biIe ducts contained stones. Partington and Sachs [22] maintain that every patient with a drainage tube in the common duct should have a choIangiogram before the tube is removed. As a ruIe these choIangiograms can be obtained on the sixth or seventh postoperative day and the surgeon then knows whether the ducts are norma or if they are obstructed by stones. Intravenous Cholangiograpby. Intravenous ChoIangiography is particuIarIy usefu1 in detecting the presence of retained stones which produce symptoms after the wounds have heaIed. McCIenahan, Evans and Braunstein [rp] stud-
The loss of biIe through an externa1 biliary fistula usuaIIy signifies ducta obstruction. If the sinus tract is injected with radiopaque material the diIated ducts and offending stones can often be visualized. ResiduaI stones may be found in the sinus tract, the choIedochus, the common hepatic bile duct and the intrahepatic radicIes. The diagnosis of “retained,” “residua1,” “overIooked” and “missed” intraducta1 stones can be accurateIy made, providing diagnostic facilities now avaiIabIe are empIoyed. TREATMENT
When the postoperative choIangiograms demonstrate the biIe ducts to contain residual caIcuIi, what happens to the unfortunate patients? A partia1 answer to such a question was obtained by folIowing the clinica course of 150 patients so affected. Information obtained from questionnaires sent to the patients, from Ietters of inquiry answered by- participating surgeons and from facts obtained by direct examination of many of the patients provides the data for this report. The time interval covered by this study ranged from one year to eighteen years. The diagnosis of “retained” caIcuIus was made by the radiofogist from postoperative chofangiograms which were obtained by injecting contrast media into indweIIing T tubes during the period of primary hospitalization. The diagnosis was positiveIy confirmed in 126 cases (84 per cent) either by operative or autopsy findings. Twenty-four patients, however, were known to have retained stones and either refused additiona treatment I77
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and WaIker had a tota of 126 operations with a mortality rate of 3.8 per cent. In the resistant group twenty-four patients refused further surgicaI therapy for various reasons: eight were so comfortable they feIt no need for a second operation, another group of eight patients were so frightened from the original surgery that they refused additional surgery in spite of annoying complaints, and eight died of unreIated diseases before the biliary compIications assumed serious proportion. It is obvious that given ample time intraducta caIcuIi invariably produce undesirabIe symptoms and complications, as 85 per cent of our patients required secondary corrective operations. GIenn [ro], Ravdin [25], and Buxton and Burk [8] beIieve that residual intraductal stones shouId be removed as soon as they are recognized, providing that the patient’s condition permits it. Non-operative Management. When confronted by retained ducta stones it is onIy natural that the surgeon would seek some method, other than reoperation, to remove the unwanted caIcuIus. Three plans have been deveIoped: (I) chemica1 dissoIution or fragmentation of the stones; (2) mechanica ffushing of the caIcuIi from the bile ducts into the duodenum by positive pressure ducta irrigations; and (3) physioIogic hydrochIoretic flushing of the ducts. In actua1 practice a combination of these methods has been tried. Chemolysis: GaIIstones consist of choIestero1, caIcium saIts, biIirubin pigments and ceIIuIar detritus. The admixture of these components varies in different forms and stones. It is obvious that any substance or soIvent which wouId dissoIve, extract or absorb any of these constituents couId resuIt in the dissoIution, disintegration or fragmentation of the stones. Many agents have been used, such as ether, ether-aIcoho1 and chloroform mixtures, with the hope that they wouId extract the choIestero1 from the stones. Agents which Iower the surface tension, such as detergent-SorIate,@ biIe acids, biIe saIts and anima1 biIe, have been empIoyed with the beIief that they penetrate or “seep” into the stone and thus faciIitate its disintegration. CaIcium binding agents, such as versene and citrates, were used because of their effects in disturbing the relationship between the insoIubIe caIcium saIts and the caIcium ions. If the agent could draw away the caIcium ions and bind them in some other soft materiaIs then
or died from unrelated diseases on which no autopsy reports couId be obtained. For practica1 purposes a11 of these patients were subdivided into three therapeutic groups : (I) those having the probIem of “retained” intraducta1 stones soIved during the period of primary hospitaIization; (2) those who were reIeased from the hospita1 but returned at a Iater date for ducta surgery; and (3) those who refused further surgica1 treatment. The primary group consisted of thirty patients (20 per cent) who had their problem of “retained” stones soIved during the period of primary hospitaIization. In twenty instances persistent jaundice, severe biIiary coIic, draining biliary fistuIas, subhepatic abscesses, subphrenic abscesses and biIe peritonitis necessitated re-expIoration with remova of the offending stones. Th ere were no operative deaths in this group. There were ten patients, however, whose postoperative choIangiograms on two or more occasions cIearIy outIined intraducta1 stones, but subsequent x-rays faiIed to detect their presence. It was assumed that these stones had been dissoIved or had passed spontaneousIy through the ampuIIary outIet into the intestina1 tract. This is not an unusua1 occurrence for Johnston et aI. [r7] described tweIve cases of retained intraductal stones; in six patients the calcuIi passed spontaneousIy into the intestina tract, and the remaining six required reoperation. SingIeton and CoIeman [26] have reported simiIar experiences. Retained caIcuIi are much more prone to pass through the ampulla if transduodenal ampuIIotomy has been performed. In the delayed group 120 patients were reIeased from the hospital foIIowing choIedochotomy, even though it was known that the Iarger biIe ducts harbored residua1 stones; ninety-six returned for remova of the obstructive caIcuIi. The time interva1 between the first and second operations varied from one month to eighteen years. One patient suffered from a persistent draining biIiary fistuIa for eIeven years before seeking relief. Nausea, vomiting, jaundice, pain, weight Ioss, fistuIas and maInutrition were the compIaints from which the patient sought reIief. In eighty-four instances a11 of the offending caIcuIi were removed at the second operation, but ten patients required three expIorations and two required six choIedochoIithotomies each. These ninety-six patients 178
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6
5
FIG. 5. Attempts to dissoIve the intrahepatic and ampuIlary stones by instillations chloroform were ineffectual. Calculi were removed at a second operation.
of ether and
FIG. 6. An attempt to dissoIve the intrahepatic stone and the large calculus in the common was unsuccessful, even after ten treatments with chloroform.
the stone might be fragmented. NaturaIIy occurring fatty acids, both the saturated and beunsaturated types, have been employed cause in vitro experiments indicated they assisted in disintegrating the stones. Hydrotrophic agents, such as biIe salts, biIe acids and anima1 biIe, have been thought to render choIestero1 and fatty acids more soIubIe. Enzymatic agents such as trypsin, Caroid@ and hyaIuronidase were found to be of use in removing the muciIaginous protecting covering of the stones and thus permitting the chemolyzing soIution to effect disintegration. Dispersmg agents, such as marasperes, function by absorbing out solid particIes and dispersing them by poIar action. Many other agents, such as strong acids, weak acids and boiIing water, have been utilized but the majority of these substances have IittIe therapeutic vaIue. Walker [2g] in 1891 introduced ethy1 ether through a choIecystostomy sinus and successfuIIy dissoIved a stone impacted in the cystic duct. Sporadic reports as to the efficacy of this method appeared in the literature but it remained for Pribram [23] in 1934 and again in 1947 to revive interest by reporting the dissolution of “residua1” gaIIstones in fifty-one cases. He attributes his success to the fact that the ether was pIaced in direct contact with the stone by a “sIow drip” instiIIation, thus keep-
duct
ing the soIvent in contact with the caIcuIus for a sufficient period of time to effect dissoIution. This requires persistence, patience and time. We empIoyed the ether instiIIation in fifteen patients with residual stones and were successfu1 in onIy one instance. Perhaps our faiIures were due to Iack of perseverance but many patients wouId not submit to repetitive instaIIations. (Fig. 5.) Chloroform is an exceIIent soIvent for choIesterol and if heated to 61’~. (141 %F.) it rapidly penetrates the gaIlstones, thereby causing disintegration. Best, Rasmussen and Wilson [6] reported exceIIent resuIts in fourteen patients. They stress the advantage of agitation obtained by injecting, aspirating and reihjecting the heated chIoroform through a T tube. Singleton and Coleman [26] Iikewise favor the use of chIoroform and beIieve that many overlooked ducta stones can be safeIy dissoIved by this method. Best, Rasmussen and Wilson [6] insist that the solubility of the stones removed at the time of cholecystectomy shouId be tested in vitro, and the most effective solvent should be selected to dissoIve the retained stones. These chemolyzing treatments are not without danger, for Burgess [7] reported that excessive vaporization pressures of ether have resulted in injury to the liver. Probstein and Eckert [zq] observed the sIoughing of duct ‘79
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” physioIogic biJiary fI ush” has been advocated, the Iatest being by Best, Rasmussen and WiIson [6]. Studies indicate that hydrochJoretic agents increase the voIume output of diIute bile by IOO to 250 per cent above normal. Johnston and Nakayama [r6] reasoned that if the Iiver produced this diIute biIe and if it continued to flow over the retained stones, there wouId be a gradua1 absorption of the stone-choIestero1; hence fragmentation wouId resuIt. Unfortunately the hydrochIoretic stimulation of the liver produces a diIute biIe which has a cholestero1 content equa1 to that of norma bile; therefore there is little influence on the stones. Johnston and Nakayama [16] treated two patients with suficient hydrochIoretic compounds to maintain an increased fJow of bile for nine to thirteen months without there being an! appreciable effect on the retained caIcuIus. Cole 191, accepting this thesis, studied nine patients with residua1 stones who also had T tubes in their common ducts. He used hydrochloretic agents to increase the fJow of biIe and then foIIowed the rate of stone absorption by progress cholangiograms. In one instance it required eIeven months for the stones to disappear. This seems to be a slow process, particuIarIy if the patient is a wage earner. We routineJy employ the “physioIogic biIiary fI ush” in a11 cases of choIeIithiasis, even though the biJe ducts have not been expJored. The increased flow of diIute biIe seems to rid the ducts of bIood clots, grave1 and ceIJuJar detritus but has IittIe effect on retained stones.
epitheIium in dogs receiving ether through a choIecystostomy tube. Amsterdam and SterJing [I], on the other hand, used daiIy instiIIation of ether for a period of eIeven months without noting untoward effects. It is common experience, however, that the high voIatiIity of both ether and chIoroform produces such high intraductal pressure that patients are nauseated, often vomit, experience severe colicky pains and often pass into a state of shock. Both Pribram [23] and Best [6] attempted to eliminate these distressing symptoms by empJoying a doubIeIumened T tube. One channe1 of the tube was used for injecting the soIvent whiIe the other acted as a vent to permit escape of the voIatiIe fumes. We have empIoyed the heated chJoroform instiIIation in sixteen patients with residua1 common duct stones and have had exceIIent results in four patients. Again, our Iack of enthusiasm for this procedure undoubtedly accounts for our high percentage of failures. (Fig. 6.) Mechanical Jushing of the bile ducts: It is quite obvious that if the choledochus contained smaI1 stones or biliary gravel these undesirable substances might be flushed from the biIe ducts by using cIeansing irrigations through an indweIIing T tube. Such a pIan wouId be more effective if the sphincter of Oddi were relaxed so the ducta outIet wouId not be obstructed. This has been accomplished by using spasmoIytic drugs, such as amy nitrate, nitrogIycerine and papaverine hydrochIoride, or by appIying such anesthetic agents as Pontocaine,@ MetyCaine@ and Nupercaine@ directIy to the sphincter by ducta instiIIations. This method has been very effective in cIeansing the ducts of bIood clots, grave1 and stones having a diameter of Jess than 2 mm. Physiologic flushing of the bile ducts: As early as 1892, Naunyn demonstrated that if human gaIJstones were placed in the gaIIbIadder of dogs they sIowIy disappeared in the course of severa months. Lutton and Large [IS], working with sheep, goats and pigs, substantiated this phenomenon. AnimaJ biJe, being Jow in cholestero1 content, sJowIy absorbs the choIestero1 from the human gaIIstones, causing them to fragment and disappear. Appreciating this fact, Best and Hicken [r;] in 1938 suggested the use of hydrochloretic agents as a method of increasing the production of hepatic biIe, which being more dilute than norma biIe might rid the bile ducts of retained debris. In numerous reports the
COMMENTS
It must be remembered that it is not the desires of the surgeon or the wishes of the patient which determine the type of treatment to be employed for residua1 intraducta1 stones. It is the condition of the patient and the nature of associated pathoJogic processes. Any attempt to dissoIve stones or mechanically flush them into the duodenum is contraindicated: (I) if the caIcuIus compIeteJy obstructs the biIe ducts; (2) if the stones are Iarger than 2 mm. in diameter; (3) if the stones Iie above the proxima1 Iimb of the T tube or within the intrahepatic radicIes; (4) if the stone is in a diverticular pocket; (5) if the patient has severe pain; (6) if there is a persistent jaundice; (7) if there is choJangitis, subhepatic abscess or biIe peritonitis; (8) if the patient’s genera1 condition is 180
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unsatisfactory; (9) if there is an excessive Ioss ferments and enzymes of bile, pancreatic through the T tube; and (IO) if the patient is anxious to assume occupational activities. AI1 of these contraindications are self-expIanatory and of necessity limit the usefulness of the nonoperative management of retained stones. Re-expIoration of the biIe ducts to remove the retained caIcuIi shouId be attempted as soon as the patient’s condition permits. It is a mistake to prolong the period of convaIescence by having the patient go home, onIy to return several months later for definitive surgery. Particular attention shouId be given to electrolyte balance, bIood voIume, bIood proteins and any signs of Iiver dysfunction. Any abnormalities shouId be corrected, if possibIe. The patients tolerate the operations better if they have been ambuIatory for a few days. The indweIIing T tube provides an exceIIent guide to the common bile duct, so IittIe difhculty need be experienced in isoIating this structure. By using operative cholangiograms the position and number of offending calculi can be accurateIy determined. Again, we wish to re-emphasize the vaIue of the compIetion choIangiogram in determining whether all stones have been removed. In our series the faiIure to remove a11 caIcuIi at the second operation was because the stones occupied the inaccessibIe intrahepatic ducts. At present this problem is insoluble. SurgicaI expIoration is mandatory in those patients suffering from intractabIe jaundice, severe pain, subhepatic abscesses or bile peritonitis. Procrastination usuaIIy resuIts in death. The risk must be accepted. The best treatment for residua1 intraductal stones is to remove them at the primary operation. WhiIe highly feasibIe, accomplishment is next to impossible. We can, however, greatly minimize the incidence of this complication by adhering to the folIowing: (I) Insist that those surgeons operating upon the extrahepatic biliary tract have special training in anatomy and ducta surgery, thus enabIing them to recognize anatomica variations and to cope with unexpected problems. (2) EmpIoy operative choIangiograms to detect ducta abnormalities, IocaIize the stones, denote the strictures and test the patency of the bite ducts. (3) Use compIetion choIangiograms before closing the abdomen to make sure a11 offending stones have been removed.
Duct
Stones REFERENCES
I.
2.
3. 4.
5.
6.
7. 8. 9. IO. II. 12.
‘3.
14.
A~ISTERDAM,G. H. and STERLING, J. H. Conservative therapy of residua1 calculi foIlowing operations on the common biIe duct. Ann. Surg., 128: 30, 1948. BAKER, J. Operative cholangiography. Surg., Gynec. e*”Obst., 101: 763-765, 1955. BEER, E. Autopsy studies on the liver. Arcb.f. klin. C&r., 74: 115, r9o4. BEST, R. R. The incidence of Iiver stones associated with ChoIelithiasis and its clinica significance. SUrg., C,ynec. PY Obst., 78: 425, 1944. BEST, R. R. and HICKEN, N. F. Nonoperative management of remaining common duct stone. J. A. M. A., 110: 1257, 1938. BEST, R. R., RASMUSSEN,J. A. and WILSON, C. E. An evaIuation of solutions for fragmentation and dissoIution of gall stones and their effect on liver and ductal tissue. Ann. Surg., 570: 581, 1953. BURGESS, C. M. Solution of gall stones. J. A. M. A., 114: 2372, 194o. BUXTON, R. and BURK, L. B. ChoIedochotomy. Surgery, 23: 76oo767, 1948. COLE, W. Recent trends in gallbladder surgery. J. A. M. A., 150: 631-637, 1952. GLENN, F. The management of common duct drainage. Surg., Cynec. & Obst., 238: 244, 1957. G LENN. F. Common duct e&oration for stones. Surg:, Gynec. Ed Obst., 95: 431, 1952. HICKEN, N. F. and MCALLISTER, A. J. Treatment of stones in common bile duct. J. Internat. Cd. Surgeons, I 8: 7055712, 1952. HICKEN, N. F., STEVENSON,V. L., FRANZ, B. and CROWDER, E. The technic of operative choIangiography. Am. J. Surg., 78: 347-355, 1949. IHICKEN,N. F.. MCALLISTER. A. J. and CALL. D. W. The problem of hepatolithiasis. Am. Skgeon, 19: 695-707. 1953. HOERR, S. Operative cholangiography as an aid in surgery for jaundice. Arch. Surg., 69: 432-443,
1954. 16. JOHNSTON,C. G. and NAKAYAMA, F. SoIubiIity of choIestero1 and gall stones in metabolic material. Arch. SUrg., 75: 436-442, 1957. 17. JOHNSTON, E. V.. WAUGH. J. M. and GOOD. G. A. Residual stones in common bile duct; the question of operative cholangiograms. Ann. Surg., 139: 293~ 1954. 18. LUTTON, R. and LARGE, A. Gal1 stones: soIubiIity studies. Surgery, 42: 488-493, 1957. ‘9. MCCLENAHAN, J. L., EVANS, J. A. and BKAUNSTEIN, P. Intravenous cholangiography in postcholecystectomy syndromes. J. A. M. A., 159: 1352, ‘955. 20. MEHN, W. H. Operating room cholangiography. S. Clin. North America, 34: 151, 1954. 21. MIXTER, C. G., HERMANSON.L. and SEGEL. A. L. Operative cholangiography; evaluation of 406 cases. Ann. Surg., 134: 346, 1951. 22. PARTINGTON. P. E. and SACHS. M. D. Routine use of operative ChoIangiography. Surg., Gvnec. Ed Obst., 87: 299-307, 1958. 23. PRIBRAM, B. 0. C. The method for dissoIution of common duct stones remaining after operation. Surgery, 22: 806, 1947. 181
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24. PROBSTEIN,J. G. and ECKERT, C. T. The injection of ether into the biliary tract as treatment for choIedochoIithiasis. Arch. Surg., 35: 258, 1937. 25. RAVDIN, I. S. ResiduaI common duct stone; discussion. Ann. Surg., 143: 619-627, 1956. 26. SINGLETON, A. 0. and COLEMAN, J. L. ResiduaI common duct calculi. Ann. Surg., 143: 619-626, 1956. 27. SMITH, S. W., ENGEL, C., AVERBKOOK, B. and LONGMIRE.W. P.. JH. ProbIems of retained and recurrent dommou biIe duct stones. J. A. M. A., 164: 231-236, 1957. 28. THOMPSON,F. B. ResiduaI stones in the biliary ducts. Surg., Gynec. ti Obst., 103: 78-84, 1956. 29. WALKEK, J. W. The removal of gal1 stones by ether soIution. Lancet, I : 874, I 891.
and WaIker DR. HICKEN: How can you teI1 which case of ChoIeIithiasis will be simpIe and which wiI1 be compIicated? As Dr. MiIIer has emphasized in his exceIIent paper on anomaIies of the extrahepatic biIiary system, at Ieast 25 per cent of the population exhibit variations in both vascuIar and biIe duct patterns. Such aberrations can be readiIy recognized by choIangiograms. Likewise, we were able to detect the presence of some stones which could not and wouId not be Iocated by paIpation. ChoIangiography does not suppIant the other methods of ducta expIoration but is a CompIementary procedure. QUESTION: How often do you get “air bubbIes” in the biIe ducts when you are performing ChoIangiography? DR. HICKEN: Remember that any air found within the biIe ducts has been introduced during the process of injecting the contrast medium. It is imperative, therefore, that the cystic duct catheter or the common duct tube be irrigated with saline, so as to dispIace the air before introducing the radiopaque materials. ShouId there be any question as to differentiation between an intraducta1 air bubbIe and the stones, mereIy repeat the choIangiograms and compare the two fiIms. Stones wil1 be present on both ChoIangiograms, whiIe air bubbIes wiI1 have shifted their positions or passed through the ampuIIa into the duodenum. DR. BYRNE: The CIeveland Clinic was mentioned as having used cholangiography. You should rise, Dr. Britton, in defense. RICHARD C. BRITTON (CIeveIand, Ohio): We empIoy both operative and postoperative choIangiography in a11 cases of biIiary tract surgery at the CIeveIand Clinic. We foIIow the method introduced by Dr. John A. Gius of Iowa, which consists of intubating the cystic duct with poIyethyIene tubing and using this to introduce the contrast media into the common biIe duct. Such a pIan minimizes the extravasation of the radiopaque materiaIs into the periducta1 tissues, and thus provides cIear ducta patterns. If you beIieve you wiI1 need the gallbladder for a by-passing operation, the cholangiogram can be obtained without any damage to the gaIIbIadder itself. One thing that characterizes surgeons is that they do not trust any one but themseIves. As we viewed the films presented by Dr. Hicken, we a11 said to ourselves, “WeII, if I had performed that operation, I wouId have removed a11 the stones”; yet in our own experience we have a11 missed intraducta stones. I shouId Iike to ask severa questions. Since you are never quite sure whether the common duct is compIeteIy “cIean,” when you go back the second time to remove stones, do you believe that sphincterotomy aIone creates an adequate channe1 for
DISCUSSION JOHN J. BYRNE (Boston, Mass.): Is there any discussion on this paper? QUESTION: I should like to ask Dr. Hicken if he considers cholesterol a binding agent, and is the dissolution of this substance the most important factor in the chemolysis of gaIlstones? DR. HICKEN: As a ruIe, gallstones are composed of varying amounts of cholesterol, calcium salts, biIe pigments, ceIIuIar detritus and mucilaginous materiaIs. ChoIesteroI, being very soIubIe in ether and chIoroform, can be more readity extracted than the more stabIe caIcium saIts. If the choIesteroI can be removed, the stone disintegrates and the residue can be flushed into the duodenum. QUESTION: Has anyone tried using short-chain hydrocarbons to dissolve gahstones? They are nontoxic and are very effective in dissoIving cholesterol the stones. DR. HICKEN: I have had no experience with hydrocarbons as soIvents for residual stones. Your idea is very good and merits investigation. Most short-chain hydrocarbons are not very voIatiIe; therefore, they shouId not produce high intraducta1 pressure which is so characteristic of ether or chloroform. LESTER B. WHITAKER (Portsmouth, N. H.): I shouId like to ask Dr. Hicken why he does not perform transduodenal sphincterotomies when there is narrowing of the choIedocha1 outIet? DR. HICKEN: We have empIoyed sphincterotomies in seIected cases, but do not advocate their use in cases of mild ducta stenosis because of the dangers arising from duodena1 fistuIa. DR. WHITAKER: I should Iike to argue for sphincterotomy just the same. DR. BYRNE: OccasionaIIy we have encountered duodena1 fistula as a compIication of sphincterotomy. There must be a definite indication before this operation is employed. QUESTION: Do you empIoy operative choIangiography as a routine procedure, even when performing a simpIe choIecystectomy?
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QUESTION: I want to ask if choledochotomy increases the postoperative mortality. DR. HICKEN: It most certainly does. Whenever the common bile duct is opened and explored there is always danger of injuring the ducts or producing hemorrhages, and even inviting biIe peritonitis. QUESTION: How frequently do you Ieave residua1 stones in the bile ducts, even though you use choIangiograms? DR. HICKEN: In our series of 150 cases in which the bile ducts were expIored, we overIooked stones in 3.2 per cent of the cases. We used operative cholangiograms to Iocate the eIusive stones. We empIoyed compIetion cholangiograms before closing the abdomen, and reopened some ducts and removed the stones; yet in spite of a11 these precautions we left stones in the Iiver and the biIe ducts. At the present time we have no method which wiI1 assure complete removal of stones from the extrahepatic biliary system. We can greatIy improve our present results by training and study. DR. BYRNE: The amount of discussion we have had is evidence of the fact that everyone has Ieft stones in the common duct.
the passage of small stones (3 mm. or Iess)? WiII contraction of the duodena1 muscuIature obviate the benefit of sphincterotomy? WouId you consider performing side-to-side choIedochoduodenostomy in such a situation? DR. HICKEN: PersonalIy, I am not a proponent of sphincterotomy, because the incised sphincter of Oddi soon heaIs and the resuIting scar tissue merely re-establishes the ducta obstruction. The sphincter of Oddi is very narrow, and if the ducta incision is more than z mm. in length it may injure the wail of the duodenum, resulting in annoying fistuIas. If the termina1 portion of the biIe duct is stenosed or narrowed, I prefer to employ side-to-side choIedochoduodenostomy or Roux-Y choIedochojejunostomy rather than depend on sphincterotomy. QUESTION: When wouId you empIoy side-to-side choIedochoduodenostomy? DR. HICKEN: I would perform this procedure if I had a poor-risk patient in whom time was an important element and in whom I could adequateIy decompress the biliary tree by anastomosing the choIedochus to the duodenum.
End of Symposium
Duct Stones
on Biliary
‘83
Surgery
Problem of Retained Duct Stones
Common
N. FREDERICK HICKEN, M.D., A. JAMES MCALLISTER, M.D. AND GLENN WALKER, Salt Lake City, Utah From tbe Surgical Service, University of Utab College of Medicine; and Latter Days Saints Hospital, Salt Lake City, Utah.
NFORTUNATELYthe actuaI accomphshments of surgery often falI short of our hopeful desires. In spite of improved diagnostic faciIities and excehence of surgica1 skiIIs we must often accept defeat, or at Ieast admit temporary faiIures. Such have been our experiences in operations upon the hepatobiliary system. We have been chagrined by our faiIure to open the bile ducts when they contained stones, and embarrassed by our inabiIity to remove a11 of the caIcuIi from the ducts which were explored. The undesirabIe compIication of “residual,” “overIooked” or “missed” intraducta1 stones occurs with annoying frequency. Pribram [2?] reported that 16 to 25 per cent of patients operated upon for choIedochoIithiasis stiI1 harbor intraductal caIcuIi. Smith et al. [27] performed 224 choIecystectomies and choIedochotomies and found that in twenty-four patients (IO per cent) a11 stones had not been removed. Thomson [28] re-expIored the biIe duct of 1o6 patients and was surprised to find that I I .6 per cent stiI1 had residual stones. Likewise, SingIeton and CoIeman [26] performed fortythree choledocholithotomies but failed to remove a11 caIcuIi in three cases, an incidence of g per cent. Buxton and Burk [8] performed leaving residual 190 choIedochoIithotomies, stones in 8.3 per cent. They aIso expIored the biIe duct of 249 patients without finding stones, yet postoperative choIangiograms demonstrated retained stones in 3.6 per cent of their cases. Glenn [lo] foIIowed up IOO patients having cholecystectomies for gaIIstones, in whom the biIe ducts were not expIored, and found that within a ten-year period 4 per cent required secondary operations for residua1 choIedocha1
U
M.D.,
stones. In performing 715 consecutive choIecystectomies for ChoIeIithiasis, we expIored the biIe duct of 232 patients (32.4 per cent); choIedocha1 stones were recovered from 105 patients (48 per cent). In four instances (3.5 per cent) we faiIed to remove a11 intraducta1 stones. Why are not a11 caIcuIi removed from the Iarger biIe ducts during choIedochotomy? In order to answer these questions the records of eIeven IocaI hospitaIs were studied, from which 150 instances of “retained” choIedocha1 stones were found. The primary operations were performed by thirty-eight different surgeons, consisting of residents, occasiona operators and certified surgeons. ResiduaI stones were missed ten times more frequentry by the occasiona operator than by the we11 trained surgeon [12]. There are certain pathoIogica1 conditions associated with choIeIithiasis which seem to prevent the compIete remova of a11 offending caIcuIi: Hepatolitbiasis. Intrahepatic caIcuIi are usuaIIy inaccessibIe and cannot be removed, yet they occur in 7.4 per cent of a11 cases of choIeIithiasis, according to Beer [j], Best [4], and Hicken, McAIIister and CaII [14]. HepatoIithiasis was found in forty-two of our patients by operative choIangiograms, and in none of them were we abIe to remove a11 the stones. (Fig. I.) In twenty-four instances the caIcuIi were found in both Iobes of the Iiver, in tweIve cases they were confined to the Ieft Iobe onIy, and in six to the right Iobe. One patient required four choIedochoIithotomies because the hepatic stones persisted in migrating down into the common duct and producing an obstructive jaundice. The last operation was performed eight years ago and she is enjoying good health in spite of the fact that she stiI1 has many intrahepatic stones. Because the surgeon can seIdom
Hicken,
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and WaIker
IB
IA
FIG. I. A, four stones were removed from the common duct and the sphincter was dilated. The postoperative cholangiogram shows an “ovedooked stone” in the right hepatic duct and obstruction of the ampulla due to pancreatic edema and swelIing. B, seven days Iater the right hepatic stone had migrated to the ampuIIary portion of the common duct. Because of the narrowing of the termina1 portion of the choIedochus, this stone was recovered at a second operation.
obstruct the common duct there is no attendant jaundice; hence the cIinica1 indications for ducta expIoration are absent. Operative choIangiograms afford the best method, for discovering these mispIaced caIcuIi. OccasionaIIy inspissated biIe and “sand” obstruct the cystic duct but are not Iarge enough to be detected by paIpation, hence are often overIooked. Such stones can and do cause symptoms. (Fig. 3.) Impacted Stones. Under certain circumstances gallstones may become impacted in the termina1 portion of the choIedochus where resuIting ducta fibrosis and infIammation intensify their incarceration. If grasping forceps are applied to such a caIcuIus the force necessary to extract the stone may be sufficient to break it into smaI1 pieces. The sharp fragments may be driven into the ducta wall, onIy to produce tissue irritation, and Iater escape into the ducta Iumen. Sometimes these fragments Aoat around in the biIe and cannot be flushed out by ducta irrigations or removed by scoops. These smaI1 sand-Iike particIes form an exceIIent nidus for the formation of new stones. Speed. Another factor which contributes to “retained” choIedocha1 stones is the tendency to rush through operations. It requires time to expose the biIe ducts adequateIy, explore their
IocaIize, Iet aIone remove, Iiver stones this particuIar phase of “retained” caIcuIus seems insoIubIe. Small Stones. Experience indicates that it is diffIcuIt to rid the biIe ducts of biliary sand and smaII caIcuIi. UnIess the stones are of a sufficient mass they do not impart an impact, or produce a “sense of scraping,” when coming in contact with the expIoring scoops, forceps and probes; hence the surgeon is unable to detect their presence. On many occasions we have thought a11 the stones had been removed from the biIe ducts and, on “passing the scoop once more just for good Iuck, ” another eIusive stone roIIed out. Likewise, we have persistentIy and thoroughIy irrigated the biIe duct to be certain that a11 bile-sand had been fIushed into the duodenum and, whiIe talking to the resident, have seen an unexpected stone float out of the ducta incision. SmaII caIcuIi can be missed, as evidenced in Figure 2. Encysted Stones. Sometimes stones become IocuIated in diverticuIar sacs of the biIe ducts and, as they do not encroach on the ducta Iumen, instruments may be passed aIong the ducts without ever coming in contact with caIcuIus. If these stones are smaI1 they cannot be detected by palpation. Because they do not 174
Retained
Common
Duct Stones
3
2
FIG.
2.
Five stones were removed from this common
duct but one small caIcuIus was “missed.”
FIG. 3. Postoperative cholangiogram outlines “overlooked” stones in left hepatic, common hepatic and choledochal ducts. The dilated stump of the cystic duct contains stones.
Just as the ducts were to be explored the anesthetist urged the surgeon to terminate the operation; hence a decompression tube was inserted into the common bile duct and the abdomen was cIosed even though stones were knowingIy Ieft behind. Nine years later she was compelIed to submit to a second operation, and the operative choIangiogram denoted a diIated biIe duct filIed with many stones. Proper preparation of the patient shouId have permitted a11 offending stones to be removed at the primary operation.
Iumen, extract contained calculi, lavage the intrahepatic radicIes and dilate the ampulla of Vater. Additiona time may be needed to perform plastic procedures upon the stenotic ampuIIary orifice. If the patient has been improperIy prepared or if he is a poor operative risk, the surgeon may be unabIe to take the necessary time to perform these corrective procedures. Figure 4 is a choledochogram of a patient who has had three operations for choIedocha1 stones “ reformed ” or “residua1” al1 because the strictured ampulIary segment of the common duct was not diIated at the primary operation. Such stenotic Iesions can be best corrected by transduodena1 ampuIIotomy or hepaticojejunostomy. Patients with ChoIelithiasis are seIdom so acutety III that ampIe time cannot be taken to prepare them for the added trauma of surgery. Even when deaIing with acute ChoIecystitis it is not necessary to perform “middIe of the Figure 3 represents the night ” operations. extrahepatic system of a patient with acute cholecystitis and jaundice. She was rushed to surgery. The gaIIbIadder was removed and the common biIe duct was found to contain stones.
DIAGNOSIS
No one wiI1 contradict the statement that every bile duct which contains stones shouId be opened and thoroughIy expIored. The enigma is, which ducts harbor caIcuIi? UnfortunateIy the conventiona criteria for choIedochotomy are not infallible. For exampIe, the size of the common duct is not an accurate guide for expIoration as many diIated ducts do not contain stones, whiIe norma or smaII-sized ducts may. PaIpation is not infaIIibIe as Buxton and Burk [8] were abIe to paIpate only 48 per cent of the choIedocha1 175
Hicken,
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4A
and
WaIker
4B
F~ti. 4. A, seven stones and some biliary sand were removed from the common duct. The postoperative cholangiogram demonstrates a stenosis of the terminal portion of the choledochus. B, eight months Iatcr the patient returned with obstructive jaundice. The operative cholangiogram outlines two large stones and obstruction of the ampuIla. ChoIedochohthotomy and transduodenal ampulIotomy were employed.
the surgeon obtains an accurate radiographic pattern of the entire biIiary system. He has a “ bIueprint ” of the probIems to be soIved. PathoIogic Iesions such as stones, kinks, strictures and neoplasms produce recognizabIe deformities. Anatomic variations in size, shape and position of the biIe duct can be quickIy recognized. This form of examination is not intended to suppIant the conventiona methods for determining the functiona status of the biIe ducts, such as inspection, paIpation and instrumenta1 expIoration, but is rather a vaIuabIe compIementary procedure. Cholangiograms provide additiona information by showing which ducts are norma (hence do not need to be expIored) and designating those which shouId be opened. In 106 choIedocholithotomies we were abIe to paIpate but 52 per cent of the stones which were removed, indicating that 48 per cent of the caIcuIi were Iocated by choIangiograms. It is interesting that in forty-two instances the ChoIangiograms outIined intrahepatic stones which couId not be detected by any other method. This agrees with the experiences of Mehn [zo] who found ten unsuspected stones in I 13 choIangiograms.
stones they removed. This means that 52 per cent of the caIculi were either too smaI1 or Iocated in such a position that they could not be detected by the paIpating fingers. Jaundice is not an accurate indication for choIedochotomy as onIy 60 per cent of our ITO cases exhibited hyperbilirubinemia even though the ducts contained stones. Examination of the statistics from the Iarger surgical centers, where we11 trained surgeons work, indicates that onIy 20 to 50 per cent of the choIedochotomies yieId caIcuIi. In simpIer terms, the conventiona indications for ducta expIoration were misIeading in 50 to 70 per cent of the cases. UnfortunateIy the indications for choledochotomy vary with the enthusiasm and experience of the surgeon, and not unti1 some exact method of diagnosis and IocaIization of intraducta1 stones are avaiIabIe wiIl these errors be minimized. As yet we have no such procedure. Operative Cholangiograpby. Since 1936 we have empIoyed operative and postoperative choIangiography as a routine procedure in more than 1,800 hepatobiIiary operations. By injecting suitabIe contrast media into the gaIIbladder and biIe ducts during the operation, 176
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Stones
ied I 2 I patients with ” postchoIecystectomy ” compIaints and were abIe to visuahze the biIe ducts in 105 instances, finding intraductal caIcuIi in eIeven cases (g per cent). InterestingIy they discovered caIcuIi in ducts having a normal diameter or caliber. GIenn [IX] recommends intravenous ChoIangiographic studies of a11 patients having choIedocho1ithotomies at intervals of one, two and three years. He believes it takes time for the smaI1 overlooked caIculi to enlarge sufhcientIy to be recognized by this method. UnfortunateIy such studies cannot be employed in the presence of jaundice, choIangitis, hepatitis, cirrhosis of the Iiver or in criticalfy ill patients; hence their diagnostic usefulness is somewhat Iimited.
Baker [2], Mixter, Hermanson and Segel [21], and Hoerr [ 151 emphasize that operative cholangiograms are not onIy usefuI in determining the presence of intraducta1 stones but also very heIpfu1 in ascertaining which ducts are normal, thus eliminating unnecessary ductal explorations. Like all diagnostic procedures, however, cholangiography has its limitations, is occasiona1Iy misleading and at times absofutelg uninformative, but what radiologic procedure is not, whether it be a urogram, an encephaIogram or an x-ray study of the gastrointestina1 tract. Experience and precision do much to reduce the percentage of errors. Completion Cbolangiograms. Whenever the common biIe duct has been opened and expIored the surgeon is always anxious to know if a11 offending caIcuIi have been removed. Such information can be obtained by injecting the T tube with a suitabIe contrast medium and obtaining a choIedochogram whiIe the abdomen is stiI1 open. Th omson [28] used completion choIangiograms in a11 choledocholithotomies and was compelled to remove the T tubes and re-explore the ducts because of retained caIcuIi in 25 per cent of his cases. We have discovered “overIooked” stones by this method in ten instances, and have removed the T tubes and extracted the eIusive caIcuIi. It is much better to detect the residua1 stone at the primary operation than be compeIIed to subject the patient to a second expIoration. Postoperative Cbolangiograpby. The onIy method for determining whether a11 stones have been removed from the bile ducts is to employ The cIinica1 postoperative choIangiograms. course provides no index as to the compIeteness of the primary choIedochoIithotomy. In more than 80 per cent of our 150 cases the patients were well enough to leave the hospita1, even though it was known that their biIe ducts contained stones. Partington and Sachs [22] maintain that every patient with a drainage tube in the common duct should have a choIangiogram before the tube is removed. As a ruIe these choIangiograms can be obtained on the sixth or seventh postoperative day and the surgeon then knows whether the ducts are norma or if they are obstructed by stones. Intravenous Cholangiograpby. Intravenous ChoIangiography is particuIarIy usefu1 in detecting the presence of retained stones which produce symptoms after the wounds have heaIed. McCIenahan, Evans and Braunstein [rp] stud-
The loss of biIe through an externa1 biliary fistula usuaIIy signifies ducta obstruction. If the sinus tract is injected with radiopaque material the diIated ducts and offending stones can often be visualized. ResiduaI stones may be found in the sinus tract, the choIedochus, the common hepatic bile duct and the intrahepatic radicIes. The diagnosis of “retained,” “residua1,” “overIooked” and “missed” intraducta1 stones can be accurateIy made, providing diagnostic facilities now avaiIabIe are empIoyed. TREATMENT
When the postoperative choIangiograms demonstrate the biIe ducts to contain residual caIcuIi, what happens to the unfortunate patients? A partia1 answer to such a question was obtained by folIowing the clinica course of 150 patients so affected. Information obtained from questionnaires sent to the patients, from Ietters of inquiry answered by- participating surgeons and from facts obtained by direct examination of many of the patients provides the data for this report. The time interval covered by this study ranged from one year to eighteen years. The diagnosis of “retained” caIcuIus was made by the radiofogist from postoperative chofangiograms which were obtained by injecting contrast media into indweIIing T tubes during the period of primary hospitalization. The diagnosis was positiveIy confirmed in 126 cases (84 per cent) either by operative or autopsy findings. Twenty-four patients, however, were known to have retained stones and either refused additiona treatment I77
Hicken,
McAIIister
and WaIker had a tota of 126 operations with a mortality rate of 3.8 per cent. In the resistant group twenty-four patients refused further surgicaI therapy for various reasons: eight were so comfortable they feIt no need for a second operation, another group of eight patients were so frightened from the original surgery that they refused additional surgery in spite of annoying complaints, and eight died of unreIated diseases before the biliary compIications assumed serious proportion. It is obvious that given ample time intraducta caIcuIi invariably produce undesirabIe symptoms and complications, as 85 per cent of our patients required secondary corrective operations. GIenn [ro], Ravdin [25], and Buxton and Burk [8] beIieve that residual intraductal stones shouId be removed as soon as they are recognized, providing that the patient’s condition permits it. Non-operative Management. When confronted by retained ducta stones it is onIy natural that the surgeon would seek some method, other than reoperation, to remove the unwanted caIcuIus. Three plans have been deveIoped: (I) chemica1 dissoIution or fragmentation of the stones; (2) mechanica ffushing of the caIcuIi from the bile ducts into the duodenum by positive pressure ducta irrigations; and (3) physioIogic hydrochIoretic flushing of the ducts. In actua1 practice a combination of these methods has been tried. Chemolysis: GaIIstones consist of choIestero1, caIcium saIts, biIirubin pigments and ceIIuIar detritus. The admixture of these components varies in different forms and stones. It is obvious that any substance or soIvent which wouId dissoIve, extract or absorb any of these constituents couId resuIt in the dissoIution, disintegration or fragmentation of the stones. Many agents have been used, such as ether, ether-aIcoho1 and chloroform mixtures, with the hope that they wouId extract the choIestero1 from the stones. Agents which Iower the surface tension, such as detergent-SorIate,@ biIe acids, biIe saIts and anima1 biIe, have been empIoyed with the beIief that they penetrate or “seep” into the stone and thus faciIitate its disintegration. CaIcium binding agents, such as versene and citrates, were used because of their effects in disturbing the relationship between the insoIubIe caIcium saIts and the caIcium ions. If the agent could draw away the caIcium ions and bind them in some other soft materiaIs then
or died from unrelated diseases on which no autopsy reports couId be obtained. For practica1 purposes a11 of these patients were subdivided into three therapeutic groups : (I) those having the probIem of “retained” intraducta1 stones soIved during the period of primary hospitaIization; (2) those who were reIeased from the hospita1 but returned at a Iater date for ducta surgery; and (3) those who refused further surgica1 treatment. The primary group consisted of thirty patients (20 per cent) who had their problem of “retained” stones soIved during the period of primary hospitaIization. In twenty instances persistent jaundice, severe biIiary coIic, draining biliary fistuIas, subhepatic abscesses, subphrenic abscesses and biIe peritonitis necessitated re-expIoration with remova of the offending stones. Th ere were no operative deaths in this group. There were ten patients, however, whose postoperative choIangiograms on two or more occasions cIearIy outIined intraducta1 stones, but subsequent x-rays faiIed to detect their presence. It was assumed that these stones had been dissoIved or had passed spontaneousIy through the ampuIIary outIet into the intestina1 tract. This is not an unusua1 occurrence for Johnston et aI. [r7] described tweIve cases of retained intraductal stones; in six patients the calcuIi passed spontaneousIy into the intestina tract, and the remaining six required reoperation. SingIeton and CoIeman [26] have reported simiIar experiences. Retained caIcuIi are much more prone to pass through the ampulla if transduodenal ampuIIotomy has been performed. In the delayed group 120 patients were reIeased from the hospital foIIowing choIedochotomy, even though it was known that the Iarger biIe ducts harbored residua1 stones; ninety-six returned for remova of the obstructive caIcuIi. The time interva1 between the first and second operations varied from one month to eighteen years. One patient suffered from a persistent draining biIiary fistuIa for eIeven years before seeking relief. Nausea, vomiting, jaundice, pain, weight Ioss, fistuIas and maInutrition were the compIaints from which the patient sought reIief. In eighty-four instances a11 of the offending caIcuIi were removed at the second operation, but ten patients required three expIorations and two required six choIedochoIithotomies each. These ninety-six patients 178
Retained
Common
Duct
Stones
6
5
FIG. 5. Attempts to dissoIve the intrahepatic and ampuIlary stones by instillations chloroform were ineffectual. Calculi were removed at a second operation.
of ether and
FIG. 6. An attempt to dissoIve the intrahepatic stone and the large calculus in the common was unsuccessful, even after ten treatments with chloroform.
the stone might be fragmented. NaturaIIy occurring fatty acids, both the saturated and beunsaturated types, have been employed cause in vitro experiments indicated they assisted in disintegrating the stones. Hydrotrophic agents, such as biIe salts, biIe acids and anima1 biIe, have been thought to render choIestero1 and fatty acids more soIubIe. Enzymatic agents such as trypsin, Caroid@ and hyaIuronidase were found to be of use in removing the muciIaginous protecting covering of the stones and thus permitting the chemolyzing soIution to effect disintegration. Dispersmg agents, such as marasperes, function by absorbing out solid particIes and dispersing them by poIar action. Many other agents, such as strong acids, weak acids and boiIing water, have been utilized but the majority of these substances have IittIe therapeutic vaIue. Walker [2g] in 1891 introduced ethy1 ether through a choIecystostomy sinus and successfuIIy dissoIved a stone impacted in the cystic duct. Sporadic reports as to the efficacy of this method appeared in the literature but it remained for Pribram [23] in 1934 and again in 1947 to revive interest by reporting the dissolution of “residua1” gaIIstones in fifty-one cases. He attributes his success to the fact that the ether was pIaced in direct contact with the stone by a “sIow drip” instiIIation, thus keep-
duct
ing the soIvent in contact with the caIcuIus for a sufficient period of time to effect dissoIution. This requires persistence, patience and time. We empIoyed the ether instiIIation in fifteen patients with residual stones and were successfu1 in onIy one instance. Perhaps our faiIures were due to Iack of perseverance but many patients wouId not submit to repetitive instaIIations. (Fig. 5.) Chloroform is an exceIIent soIvent for choIesterol and if heated to 61’~. (141 %F.) it rapidly penetrates the gaIlstones, thereby causing disintegration. Best, Rasmussen and Wilson [6] reported exceIIent resuIts in fourteen patients. They stress the advantage of agitation obtained by injecting, aspirating and reihjecting the heated chIoroform through a T tube. Singleton and Coleman [26] Iikewise favor the use of chIoroform and beIieve that many overlooked ducta stones can be safeIy dissoIved by this method. Best, Rasmussen and Wilson [6] insist that the solubility of the stones removed at the time of cholecystectomy shouId be tested in vitro, and the most effective solvent should be selected to dissoIve the retained stones. These chemolyzing treatments are not without danger, for Burgess [7] reported that excessive vaporization pressures of ether have resulted in injury to the liver. Probstein and Eckert [zq] observed the sIoughing of duct ‘79
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McAIIister
and
WaIker
” physioIogic biJiary fI ush” has been advocated, the Iatest being by Best, Rasmussen and WiIson [6]. Studies indicate that hydrochJoretic agents increase the voIume output of diIute bile by IOO to 250 per cent above normal. Johnston and Nakayama [r6] reasoned that if the Iiver produced this diIute biIe and if it continued to flow over the retained stones, there wouId be a gradua1 absorption of the stone-choIestero1; hence fragmentation wouId resuIt. Unfortunately the hydrochIoretic stimulation of the liver produces a diIute biIe which has a cholestero1 content equa1 to that of norma bile; therefore there is little influence on the stones. Johnston and Nakayama [16] treated two patients with suficient hydrochIoretic compounds to maintain an increased fJow of bile for nine to thirteen months without there being an! appreciable effect on the retained caIcuIus. Cole 191, accepting this thesis, studied nine patients with residua1 stones who also had T tubes in their common ducts. He used hydrochloretic agents to increase the fJow of biIe and then foIIowed the rate of stone absorption by progress cholangiograms. In one instance it required eIeven months for the stones to disappear. This seems to be a slow process, particuIarIy if the patient is a wage earner. We routineJy employ the “physioIogic biIiary fI ush” in a11 cases of choIeIithiasis, even though the biJe ducts have not been expJored. The increased flow of diIute biIe seems to rid the ducts of bIood clots, grave1 and ceIJuJar detritus but has IittIe effect on retained stones.
epitheIium in dogs receiving ether through a choIecystostomy tube. Amsterdam and SterJing [I], on the other hand, used daiIy instiIIation of ether for a period of eIeven months without noting untoward effects. It is common experience, however, that the high voIatiIity of both ether and chIoroform produces such high intraductal pressure that patients are nauseated, often vomit, experience severe colicky pains and often pass into a state of shock. Both Pribram [23] and Best [6] attempted to eliminate these distressing symptoms by empJoying a doubIeIumened T tube. One channe1 of the tube was used for injecting the soIvent whiIe the other acted as a vent to permit escape of the voIatiIe fumes. We have empIoyed the heated chJoroform instiIIation in sixteen patients with residua1 common duct stones and have had exceIIent results in four patients. Again, our Iack of enthusiasm for this procedure undoubtedly accounts for our high percentage of failures. (Fig. 6.) Mechanical Jushing of the bile ducts: It is quite obvious that if the choledochus contained smaI1 stones or biliary gravel these undesirable substances might be flushed from the biIe ducts by using cIeansing irrigations through an indweIIing T tube. Such a pIan wouId be more effective if the sphincter of Oddi were relaxed so the ducta outIet wouId not be obstructed. This has been accomplished by using spasmoIytic drugs, such as amy nitrate, nitrogIycerine and papaverine hydrochIoride, or by appIying such anesthetic agents as Pontocaine,@ MetyCaine@ and Nupercaine@ directIy to the sphincter by ducta instiIIations. This method has been very effective in cIeansing the ducts of bIood clots, grave1 and stones having a diameter of Jess than 2 mm. Physiologic flushing of the bile ducts: As early as 1892, Naunyn demonstrated that if human gaIJstones were placed in the gaIIbIadder of dogs they sIowIy disappeared in the course of severa months. Lutton and Large [IS], working with sheep, goats and pigs, substantiated this phenomenon. AnimaJ biJe, being Jow in cholestero1 content, sJowIy absorbs the choIestero1 from the human gaIIstones, causing them to fragment and disappear. Appreciating this fact, Best and Hicken [r;] in 1938 suggested the use of hydrochloretic agents as a method of increasing the production of hepatic biIe, which being more dilute than norma biIe might rid the bile ducts of retained debris. In numerous reports the
COMMENTS
It must be remembered that it is not the desires of the surgeon or the wishes of the patient which determine the type of treatment to be employed for residua1 intraducta1 stones. It is the condition of the patient and the nature of associated pathoJogic processes. Any attempt to dissoIve stones or mechanically flush them into the duodenum is contraindicated: (I) if the caIcuIus compIeteJy obstructs the biIe ducts; (2) if the stones are Iarger than 2 mm. in diameter; (3) if the stones Iie above the proxima1 Iimb of the T tube or within the intrahepatic radicIes; (4) if the stone is in a diverticular pocket; (5) if the patient has severe pain; (6) if there is a persistent jaundice; (7) if there is choJangitis, subhepatic abscess or biIe peritonitis; (8) if the patient’s genera1 condition is 180
Retained
Common
unsatisfactory; (9) if there is an excessive Ioss ferments and enzymes of bile, pancreatic through the T tube; and (IO) if the patient is anxious to assume occupational activities. AI1 of these contraindications are self-expIanatory and of necessity limit the usefulness of the nonoperative management of retained stones. Re-expIoration of the biIe ducts to remove the retained caIcuIi shouId be attempted as soon as the patient’s condition permits. It is a mistake to prolong the period of convaIescence by having the patient go home, onIy to return several months later for definitive surgery. Particular attention shouId be given to electrolyte balance, bIood voIume, bIood proteins and any signs of Iiver dysfunction. Any abnormalities shouId be corrected, if possibIe. The patients tolerate the operations better if they have been ambuIatory for a few days. The indweIIing T tube provides an exceIIent guide to the common bile duct, so IittIe difhculty need be experienced in isoIating this structure. By using operative cholangiograms the position and number of offending calculi can be accurateIy determined. Again, we wish to re-emphasize the vaIue of the compIetion choIangiogram in determining whether all stones have been removed. In our series the faiIure to remove a11 caIcuIi at the second operation was because the stones occupied the inaccessibIe intrahepatic ducts. At present this problem is insoluble. SurgicaI expIoration is mandatory in those patients suffering from intractabIe jaundice, severe pain, subhepatic abscesses or bile peritonitis. Procrastination usuaIIy resuIts in death. The risk must be accepted. The best treatment for residua1 intraductal stones is to remove them at the primary operation. WhiIe highly feasibIe, accomplishment is next to impossible. We can, however, greatly minimize the incidence of this complication by adhering to the folIowing: (I) Insist that those surgeons operating upon the extrahepatic biliary tract have special training in anatomy and ducta surgery, thus enabIing them to recognize anatomica variations and to cope with unexpected problems. (2) EmpIoy operative choIangiograms to detect ducta abnormalities, IocaIize the stones, denote the strictures and test the patency of the bite ducts. (3) Use compIetion choIangiograms before closing the abdomen to make sure a11 offending stones have been removed.
Duct
Stones REFERENCES
I.
2.
3. 4.
5.
6.
7. 8. 9. IO. II. 12.
‘3.
14.
A~ISTERDAM,G. H. and STERLING, J. H. Conservative therapy of residua1 calculi foIlowing operations on the common biIe duct. Ann. Surg., 128: 30, 1948. BAKER, J. Operative cholangiography. Surg., Gynec. e*”Obst., 101: 763-765, 1955. BEER, E. Autopsy studies on the liver. Arcb.f. klin. C&r., 74: 115, r9o4. BEST, R. R. The incidence of Iiver stones associated with ChoIelithiasis and its clinica significance. SUrg., C,ynec. PY Obst., 78: 425, 1944. BEST, R. R. and HICKEN, N. F. Nonoperative management of remaining common duct stone. J. A. M. A., 110: 1257, 1938. BEST, R. R., RASMUSSEN,J. A. and WILSON, C. E. An evaIuation of solutions for fragmentation and dissoIution of gall stones and their effect on liver and ductal tissue. Ann. Surg., 570: 581, 1953. BURGESS, C. M. Solution of gall stones. J. A. M. A., 114: 2372, 194o. BUXTON, R. and BURK, L. B. ChoIedochotomy. Surgery, 23: 76oo767, 1948. COLE, W. Recent trends in gallbladder surgery. J. A. M. A., 150: 631-637, 1952. GLENN, F. The management of common duct drainage. Surg., Cynec. & Obst., 238: 244, 1957. G LENN. F. Common duct e&oration for stones. Surg:, Gynec. Ed Obst., 95: 431, 1952. HICKEN, N. F. and MCALLISTER, A. J. Treatment of stones in common bile duct. J. Internat. Cd. Surgeons, I 8: 7055712, 1952. HICKEN, N. F., STEVENSON,V. L., FRANZ, B. and CROWDER, E. The technic of operative choIangiography. Am. J. Surg., 78: 347-355, 1949. IHICKEN,N. F.. MCALLISTER. A. J. and CALL. D. W. The problem of hepatolithiasis. Am. Skgeon, 19: 695-707. 1953. HOERR, S. Operative cholangiography as an aid in surgery for jaundice. Arch. Surg., 69: 432-443,
1954. 16. JOHNSTON,C. G. and NAKAYAMA, F. SoIubiIity of choIestero1 and gall stones in metabolic material. Arch. SUrg., 75: 436-442, 1957. 17. JOHNSTON, E. V.. WAUGH. J. M. and GOOD. G. A. Residual stones in common bile duct; the question of operative cholangiograms. Ann. Surg., 139: 293~ 1954. 18. LUTTON, R. and LARGE, A. Gal1 stones: soIubiIity studies. Surgery, 42: 488-493, 1957. ‘9. MCCLENAHAN, J. L., EVANS, J. A. and BKAUNSTEIN, P. Intravenous cholangiography in postcholecystectomy syndromes. J. A. M. A., 159: 1352, ‘955. 20. MEHN, W. H. Operating room cholangiography. S. Clin. North America, 34: 151, 1954. 21. MIXTER, C. G., HERMANSON.L. and SEGEL. A. L. Operative cholangiography; evaluation of 406 cases. Ann. Surg., 134: 346, 1951. 22. PARTINGTON. P. E. and SACHS. M. D. Routine use of operative ChoIangiography. Surg., Gvnec. Ed Obst., 87: 299-307, 1958. 23. PRIBRAM, B. 0. C. The method for dissoIution of common duct stones remaining after operation. Surgery, 22: 806, 1947. 181
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24. PROBSTEIN,J. G. and ECKERT, C. T. The injection of ether into the biliary tract as treatment for choIedochoIithiasis. Arch. Surg., 35: 258, 1937. 25. RAVDIN, I. S. ResiduaI common duct stone; discussion. Ann. Surg., 143: 619-627, 1956. 26. SINGLETON, A. 0. and COLEMAN, J. L. ResiduaI common duct calculi. Ann. Surg., 143: 619-626, 1956. 27. SMITH, S. W., ENGEL, C., AVERBKOOK, B. and LONGMIRE.W. P.. JH. ProbIems of retained and recurrent dommou biIe duct stones. J. A. M. A., 164: 231-236, 1957. 28. THOMPSON,F. B. ResiduaI stones in the biliary ducts. Surg., Gynec. ti Obst., 103: 78-84, 1956. 29. WALKEK, J. W. The removal of gal1 stones by ether soIution. Lancet, I : 874, I 891.
and WaIker DR. HICKEN: How can you teI1 which case of ChoIeIithiasis will be simpIe and which wiI1 be compIicated? As Dr. MiIIer has emphasized in his exceIIent paper on anomaIies of the extrahepatic biIiary system, at Ieast 25 per cent of the population exhibit variations in both vascuIar and biIe duct patterns. Such aberrations can be readiIy recognized by choIangiograms. Likewise, we were able to detect the presence of some stones which could not and wouId not be Iocated by paIpation. ChoIangiography does not suppIant the other methods of ducta expIoration but is a CompIementary procedure. QUESTION: How often do you get “air bubbIes” in the biIe ducts when you are performing ChoIangiography? DR. HICKEN: Remember that any air found within the biIe ducts has been introduced during the process of injecting the contrast medium. It is imperative, therefore, that the cystic duct catheter or the common duct tube be irrigated with saline, so as to dispIace the air before introducing the radiopaque materials. ShouId there be any question as to differentiation between an intraducta1 air bubbIe and the stones, mereIy repeat the choIangiograms and compare the two fiIms. Stones wil1 be present on both ChoIangiograms, whiIe air bubbIes wiI1 have shifted their positions or passed through the ampuIIa into the duodenum. DR. BYRNE: The CIeveland Clinic was mentioned as having used cholangiography. You should rise, Dr. Britton, in defense. RICHARD C. BRITTON (CIeveIand, Ohio): We empIoy both operative and postoperative choIangiography in a11 cases of biIiary tract surgery at the CIeveIand Clinic. We foIIow the method introduced by Dr. John A. Gius of Iowa, which consists of intubating the cystic duct with poIyethyIene tubing and using this to introduce the contrast media into the common biIe duct. Such a pIan minimizes the extravasation of the radiopaque materiaIs into the periducta1 tissues, and thus provides cIear ducta patterns. If you beIieve you wiI1 need the gallbladder for a by-passing operation, the cholangiogram can be obtained without any damage to the gaIIbIadder itself. One thing that characterizes surgeons is that they do not trust any one but themseIves. As we viewed the films presented by Dr. Hicken, we a11 said to ourselves, “WeII, if I had performed that operation, I wouId have removed a11 the stones”; yet in our own experience we have a11 missed intraducta stones. I shouId Iike to ask severa questions. Since you are never quite sure whether the common duct is compIeteIy “cIean,” when you go back the second time to remove stones, do you believe that sphincterotomy aIone creates an adequate channe1 for
DISCUSSION JOHN J. BYRNE (Boston, Mass.): Is there any discussion on this paper? QUESTION: I should like to ask Dr. Hicken if he considers cholesterol a binding agent, and is the dissolution of this substance the most important factor in the chemolysis of gaIlstones? DR. HICKEN: As a ruIe, gallstones are composed of varying amounts of cholesterol, calcium salts, biIe pigments, ceIIuIar detritus and mucilaginous materiaIs. ChoIesteroI, being very soIubIe in ether and chIoroform, can be more readity extracted than the more stabIe caIcium saIts. If the choIesteroI can be removed, the stone disintegrates and the residue can be flushed into the duodenum. QUESTION: Has anyone tried using short-chain hydrocarbons to dissolve gahstones? They are nontoxic and are very effective in dissoIving cholesterol the stones. DR. HICKEN: I have had no experience with hydrocarbons as soIvents for residual stones. Your idea is very good and merits investigation. Most short-chain hydrocarbons are not very voIatiIe; therefore, they shouId not produce high intraducta1 pressure which is so characteristic of ether or chloroform. LESTER B. WHITAKER (Portsmouth, N. H.): I shouId like to ask Dr. Hicken why he does not perform transduodenal sphincterotomies when there is narrowing of the choIedocha1 outIet? DR. HICKEN: We have empIoyed sphincterotomies in seIected cases, but do not advocate their use in cases of mild ducta stenosis because of the dangers arising from duodena1 fistuIa. DR. WHITAKER: I should Iike to argue for sphincterotomy just the same. DR. BYRNE: OccasionaIIy we have encountered duodena1 fistula as a compIication of sphincterotomy. There must be a definite indication before this operation is employed. QUESTION: Do you empIoy operative choIangiography as a routine procedure, even when performing a simpIe choIecystectomy?
182
Retained
Common
QUESTION: I want to ask if choledochotomy increases the postoperative mortality. DR. HICKEN: It most certainly does. Whenever the common bile duct is opened and explored there is always danger of injuring the ducts or producing hemorrhages, and even inviting biIe peritonitis. QUESTION: How frequently do you Ieave residua1 stones in the bile ducts, even though you use choIangiograms? DR. HICKEN: In our series of 150 cases in which the bile ducts were expIored, we overIooked stones in 3.2 per cent of the cases. We used operative cholangiograms to Iocate the eIusive stones. We empIoyed compIetion cholangiograms before closing the abdomen, and reopened some ducts and removed the stones; yet in spite of a11 these precautions we left stones in the Iiver and the biIe ducts. At the present time we have no method which wiI1 assure complete removal of stones from the extrahepatic biliary system. We can greatIy improve our present results by training and study. DR. BYRNE: The amount of discussion we have had is evidence of the fact that everyone has Ieft stones in the common duct.
the passage of small stones (3 mm. or Iess)? WiII contraction of the duodena1 muscuIature obviate the benefit of sphincterotomy? WouId you consider performing side-to-side choIedochoduodenostomy in such a situation? DR. HICKEN: PersonalIy, I am not a proponent of sphincterotomy, because the incised sphincter of Oddi soon heaIs and the resuIting scar tissue merely re-establishes the ducta obstruction. The sphincter of Oddi is very narrow, and if the ducta incision is more than z mm. in length it may injure the wail of the duodenum, resulting in annoying fistuIas. If the termina1 portion of the biIe duct is stenosed or narrowed, I prefer to employ side-to-side choIedochoduodenostomy or Roux-Y choIedochojejunostomy rather than depend on sphincterotomy. QUESTION: When wouId you empIoy side-to-side choIedochoduodenostomy? DR. HICKEN: I would perform this procedure if I had a poor-risk patient in whom time was an important element and in whom I could adequateIy decompress the biliary tree by anastomosing the choIedochus to the duodenum.
End of Symposium
Duct Stones
on Biliary
‘83
Surgery