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Efficacy of ceruletide controlled saline infusion for retained ductal stones after cholecystectomy and exploration of the common bile duct
288
Journal¢~l'H{7~atolog3'. 1987: 5' 288-291 Elsevtcr
HEP 00352
Efficacy of ceruletide controlled saline infusion for retained ductal stones after cholecystectomy and exploration of the common bile duct
S. Sadek and A. Cuschieri Deparmwnt of Surgery, Ninewells Hospital and Medical School, Universi O, of Dundee, Dundee (U. K. )
(Received 6 January, 1987) (Accepted 2 July, 1987)
Summary The synthetic peptide ceruletide induces maximal relaxation of the sphincter of Oddi. In a preliminary c o m m u nication, ceruletide controlled saline infusion of the c o m m o n bile duct ( C B D ) was found to be effective in promoting the passage of retained ductal calculi after cholecystectomy and exploration of the c o m m o n bile duct. This paper reports on the further experience with this simple treatment which was administered to 27 patients with retained ductal calculi in 16 different hospitals within the U.K. The success of the p r o c e d u r e was documented by repeat T-tube cholangiography. Passage of stones into the d u o d e n u m was d o c u m e n t e d in 13 patients (48%) with complete clearance in 9 (33%) following one saline infusion/ceruletide treatment. The radiological stone size ranged from 3 to 15 mm. Within this range, there was no correlation between a successful o u t c o m e and size of retained stones. The duration of the saline T-tube infusion during ceruletlde treatment averaged 54.7/rain (SD 14.3). There was no correlation between flow rate of saline through the T-tube and a successful outcome. A significant inverse correlation was observed between the C B D pressure during ceruletide controlled saline T-tube infusion and successful stone passage (Z2 = - 9 . 9 , P < 0.01 ). A m p u l l a r y impaction by a stone was encountered in one patmnt. These results are encouraging and mdicate that pharmacological dilatation of the sphincter of Oddi together with saline infusion is effective in the m a n a g e m e n t of retained stones after exploration of the common bile duct. This treatment, which does not require any specml expertise, should be tried in the first instance before more invasive procedures are used.
Introduction The reported incidence in retrospective studies of
retained ductal stones after exploration of the common bile duct varies from 5 - 1 5 % . The prospective study carried out by the International Biliary Asso-
Correspondence: Prof. A. Cuschieri, Department of Surgery, Ninewells Hospital and Medical School, Dundee DDI 9SY, U.K. 0168-8278/87/$03.50 ~ 1987 Elsevier Science Publishers B.V. (Biomedical Dwlsion)
CERULETIDE TREATMENT OF RETAINED DUCTAL CALCULI ciation in 21 institutions with special interest in biliary tract surgery showed a residual stone rate of 4.5% [1]. The current methods available for dealing with this problem include extraction via the T-tube tract by the Burhenne technique [2] or preferably by the flexible choledochoscope [3], endoscopic sphincterotomy and stone extraction [4] or dissolution by intraductal infusion of monooctanoin [5,6] and, more recently, methyl tert-butyl ether [7]. The relative efficacy of these different modalities has never been assessed. However, they all carry a small but definite morbidity. Extraction of the residual stones via the T-tube tract requires a 4-6-week period of maturation of the T-tube tract before the method can be safely employed. Pharmacological dilatation of the lower sphincteric complex of the c o m m o n bile duct can be achieved by a number of drugs. In this respect, the synthetic peptide ceruletide has a pronounced relaxant effect on the sphincter of Oddi [8]. This decapeptide, which is the synthetic equivalent of the naturally occurring caerulein, is chemically closely related to gastrin and cholecystokinin. It has a pronounced cholecystokinetic response, and stimulates pancreatic exocrine secretion and intestinal peristaltic contractile activity. In a preliminary report, the intravenous infusion of this peptide was observed to facilitate the passage of residual calculi into the duodenum following saline infusion via the long limb of the T-tube [9]. This paper reports the results obtained in 27 patients treated by this technique in a number of U.K. hospitals.
Patients and Methods
The group of patients treated consisted of 16 females and 11 males who had undergone cholecystectomy and exploration of the c o m m o n bile duct. The age of the patients varied from 27 to 92 years, with a mean of 60 years. The residual stones were diagnosed on the post-operative T-tube cholangiogram. Six patients had two or more residual stones. The radiological stone size varied from 3 to 15 mm, median 9mm.
289
The technique employed involved the administration of ceruletide (Farmitalia Carlo Erba) intravenously in a dose of 2 ng/kg/min in saline for 1 h as a constant infusion. Five minutes after the start of the ceruletide infusion, sterile isotonic saline was infused via a disposable manometry line through the external limb of the T-tube for a period of 1 h. The biliary pressure was momtored through the U-limb of the manometry line used to infuse saline in the common bile duct. Intraductal saline was administered at a rate which did not result in a significant rise in the biliary pressure. Three patients received two separate ceruletide/ductal saline infusion treatments. The procedure was covered with systemic antibiotics, the detads of which varied from hospital to hospital. The efficacy of the treatment was assessed by repeat T-tube cholangiography in all the patients.
Results
There were minor departures from the intended protocol. Thus, the mean dose of ceruletide administered to the patients in the study was 1.98 ng/kg/min (SD 0.80). The duration of saline infusion was 54.7 min (SD 14.3), and the amount of saline infused into the T-tube varied from 0.1 to 3.0 litres with a mean of 1.2 litres. Complete clearance was achieved in 9 patients (33%) after one treatment. In a further 4 patients, passage of some stones was documented but residual calculi were still present on the post-treatment cholangiogram. One of these patients achieved complete clearance after a further treatment with ceruletide and saline infusion 1 day later. The treatment was completely unsuccessful in 14 patients (Table 1). This TABLE 1 EFFICACY THERAPY
OF
CERULETIDE/SALINE
Result
No.
Complete clearance Partial clearance Failure
9 42 14
INFUSION
a Complete clearance in one patient after second treatment.
290
s. SADEK and A. CUSCHIERI
TABLE 2
TABLE 4
OUTCOME VS. RADIOLOGICAL STONE SIZE
SIDE EFFECTS OF TREATMENT
Size (mm)
No.
3-5 6-10 11-15
11 10 4
Clearance
Failure
complete
partial
3 3 3
2 2 0
6 5 1
7(2 = 3.5 (4 df); not significant.
na
Nausea/vomiting Abdominal pain/discomfort Diarrhoea Pyrexia Stone impaction
5 6 4 1 1
d 17 side effects in I0 patients.
included one patient in whom ampullary stone impaction occurred and required endoscopic sphincterotomy. Within the range of stone size e n c o u n t e r e d in the study, there was no correlation between a successful outcome and radiological stone size (Table 2). Details of the biliary pressure during saline infusion through the c o m m o n bile duct were available in 19 patients. The biliary pressure did not exceed 25 cm H20 during saline infusion in 7 patients. The treatment was successful in all these patients (complete in 5, partial in 2) whereas stone clearance was encountered in only 3 out of 12 patients in whom the biliary pressure exceeded 27 cm H 2 0 (Table 3). No correlation was found between passage of stones and flow rate of saline through the T-tube. The side effects of ceruletide t r e a t m e n t are outlined in Table 4. Colicky a b d o m i n a l pain was encountered in 6 patients, usually at the start of the saline infusion. F o u r of these patients achieved complete clearance of the ductai calculi. O t h e r side effects included nausea/vomiting in 5 and d i a r r h o e a in 4. The latter was only e n c o u n t e r e d in patients who received 1 litre or more of saline infusion into the c o m m o n bile duct. T r e a t m e n t had to be stopped p r e m a t u r e l y in one patient who d e v e l o p e d severe pain due to impac-
TABLE 3 OUTCOME VS. BILIARY PRESSURE DURING SALINE INFUSION IN 19 PATIENTS Pressure (em H20 )
No.
Clearance complete
partial
0-25 26-45
7 12
5 1
2 2
X2 = 9.9 (2df);P<0.01.
Side effect
Failure 0 9
tion of the stone in the ampulla of Vater. This patient required endoscopic sphincterotomy. All the other side effects were not severe and limited to the duration of treatment.
Discussion The results o b t a i n e d with ceruletide controlled saline infusion of the c o m m o n bile duct in this study compare very favourably with those of stone dissolution by the intraductal infusion of m o n o o c t a n o i n [10]. This treatment is unequivocally successful in 33% of patients and partially so in 13%. The results of the present ceruletide study are better than those reported following t r e a t m e n t with sodium cholate [11] or heparin solution [12], but they are u n d o u b t e d l y inferior to those o b t a i n e d by either endoscopic sphincterotomy or extraction via the T-tube tract. The ceruletide treatment is, however, completely non-invasive, does not require any special expertise and is easy to administer. F u r t h e r m o r e , it was not accompanied by any serious or life-threatening complications. Side effects were e n c o u n t e r e d in this study. They were short of duration and limited to the period of infusion. The abdominal pain and the d i a r r h o e a are due to the saline infusion into the c o m m o n bile duct, but the nausea and vomiting, which occurred in 18% of patients, a p p e a r to be direct side effects of ceruletide administration and we have e n c o u n t e r e d them when this p e p t i d e has been used in other clinical situations, such as paralytic ileus or pseudo-obstruction. W e would now r e c o m m e n d that the patients be p r e m e d i cared with an anti-emetic before the start of the ceruletide therapy.
CERULETIDE TREATMENT OF RETAINED DUCTAL CALCULI This study confirms the efficacy of ceruletide controlled ductal saline infusion in patients with retained ductai calculi, but a prospective controlled clinical trial is needed to confirm the beneficial effect of ceruletide over ductal saline infusion alone. Meantime, this treatment should be considered in patients with retained ductal calculi as a first-line measure. Its use may avoid the need for more invasive procedures such as endoscopic sphincterotomy or stone extraction via the T-tube tract.
Participating clinicians Mr. C. Mackie, Walton Hospital, Liverpool; Mr.
References 1 DenBesten L, Berci G. The current status of biliary tract surgery: An international study of 1072 consecutive patients. World J Surg 1986; 10:116-122. 2 Burhenne JJ. Nonoperative retained stone extraction. Am J Roentgenol 1973; 117: 388-399. 3 Yamakawa T. An improved choledocho-fiberscope and non-surgical removal of retained biliary calculi under direct visual control. Gastrointest Endosc 1976; 22: 160-165. 4 Cotton PB. Endoscopic management of bile duct stones: (Apples and oranges). Gut 1984; 25: 587-597. 5 Thistle JL, Carlson GL, Hofmann AF, et al. Monooctanoin, a dissolution agent for retained cholesterol bile duct stones: physical properties and clinical application. Gastroenterology 1980; 78: 1016-1022. 6 Hofmann AF, Schmack B, Thistle JL, Babayan VK. Clinical experience with monooctanoin for dissolution of bile duct stones. An uncontrolled multicentre trial. Dig Dis Sci
291
R. Crosbie, Arrow Park Hospital, Wirral; Mr. D. Brown, Derriford General Hospital, Plymouth; Mr. A.N. Hamlyn, Russells Hall Hospital, West Midlands; Mr. J.E. Hale, East Surrey Hospital, Surrey; Mr. G.R. MacLatchie, Hartlepool General Hospital, Hartlepool; Mr. Williams, Nottingham District Hospital, Nottingham; Mr. P.J. Pheils, Isle of T h a n e t District Hospital, Margate; Mr. W. Lloyd-Jones, Broadgreen Hospital Liverpool; Mr. T. Preston, Whiston Hospital, Prescot; Mr. M. Colmer, St. Helens Hospital, St. Helens; Mr. E.M. Macllrath, Royal Victoria Hospital, Belfast; Mr. A . G . Cox, Northwick Park Hospital, Middlesex; Dr. R. Mendelson, Royal Liverpool Hospital, Liverpool; Mr. M. Knight, St. James's Hospital, London.
1981; 26: 954-955. 7 Allen MJ, Borody TJ, Bugliosi TF, et al. Rapid dissolution of gallstones in humans using methyl tert-butyl ether. New Engl J Med 1985; 312: 217-220. 8 Ganzina F, Santamaria A. Caerulein (ceruletide). A review. Acta Gastroenterol Belg 1976; 39: 169-185. 9 Cuschieri A. Management of retained biliary calculi: relaxation of sphincter induced by ceruletide. Br Med J 1984; 289: 1582. 10 Palmer KR, Hofmann AF. Intraductal mono-octanoin for the direct dissolution of bile duct stones: experience in 343 patients. Gut 1986; 27: 196-202. 11 Lansford C, Mehta S, Kern F Jr. The treatment of retained stones in the common bile duct with sodium cholate infusion. Gut 1974; 15: 48-51. 12 Gardner B. Experience with the use of intracholedochal heparinized saline for the treatment of retained common duct stones. Ann Surg 1973; 240-244.
Journal¢~l'H{7~atolog3'. 1987: 5' 288-291 Elsevtcr
HEP 00352
Efficacy of ceruletide controlled saline infusion for retained ductal stones after cholecystectomy and exploration of the common bile duct
S. Sadek and A. Cuschieri Deparmwnt of Surgery, Ninewells Hospital and Medical School, Universi O, of Dundee, Dundee (U. K. )
(Received 6 January, 1987) (Accepted 2 July, 1987)
Summary The synthetic peptide ceruletide induces maximal relaxation of the sphincter of Oddi. In a preliminary c o m m u nication, ceruletide controlled saline infusion of the c o m m o n bile duct ( C B D ) was found to be effective in promoting the passage of retained ductal calculi after cholecystectomy and exploration of the c o m m o n bile duct. This paper reports on the further experience with this simple treatment which was administered to 27 patients with retained ductal calculi in 16 different hospitals within the U.K. The success of the p r o c e d u r e was documented by repeat T-tube cholangiography. Passage of stones into the d u o d e n u m was d o c u m e n t e d in 13 patients (48%) with complete clearance in 9 (33%) following one saline infusion/ceruletide treatment. The radiological stone size ranged from 3 to 15 mm. Within this range, there was no correlation between a successful o u t c o m e and size of retained stones. The duration of the saline T-tube infusion during ceruletlde treatment averaged 54.7/rain (SD 14.3). There was no correlation between flow rate of saline through the T-tube and a successful outcome. A significant inverse correlation was observed between the C B D pressure during ceruletide controlled saline T-tube infusion and successful stone passage (Z2 = - 9 . 9 , P < 0.01 ). A m p u l l a r y impaction by a stone was encountered in one patmnt. These results are encouraging and mdicate that pharmacological dilatation of the sphincter of Oddi together with saline infusion is effective in the m a n a g e m e n t of retained stones after exploration of the common bile duct. This treatment, which does not require any specml expertise, should be tried in the first instance before more invasive procedures are used.
Introduction The reported incidence in retrospective studies of
retained ductal stones after exploration of the common bile duct varies from 5 - 1 5 % . The prospective study carried out by the International Biliary Asso-
Correspondence: Prof. A. Cuschieri, Department of Surgery, Ninewells Hospital and Medical School, Dundee DDI 9SY, U.K. 0168-8278/87/$03.50 ~ 1987 Elsevier Science Publishers B.V. (Biomedical Dwlsion)
CERULETIDE TREATMENT OF RETAINED DUCTAL CALCULI ciation in 21 institutions with special interest in biliary tract surgery showed a residual stone rate of 4.5% [1]. The current methods available for dealing with this problem include extraction via the T-tube tract by the Burhenne technique [2] or preferably by the flexible choledochoscope [3], endoscopic sphincterotomy and stone extraction [4] or dissolution by intraductal infusion of monooctanoin [5,6] and, more recently, methyl tert-butyl ether [7]. The relative efficacy of these different modalities has never been assessed. However, they all carry a small but definite morbidity. Extraction of the residual stones via the T-tube tract requires a 4-6-week period of maturation of the T-tube tract before the method can be safely employed. Pharmacological dilatation of the lower sphincteric complex of the c o m m o n bile duct can be achieved by a number of drugs. In this respect, the synthetic peptide ceruletide has a pronounced relaxant effect on the sphincter of Oddi [8]. This decapeptide, which is the synthetic equivalent of the naturally occurring caerulein, is chemically closely related to gastrin and cholecystokinin. It has a pronounced cholecystokinetic response, and stimulates pancreatic exocrine secretion and intestinal peristaltic contractile activity. In a preliminary report, the intravenous infusion of this peptide was observed to facilitate the passage of residual calculi into the duodenum following saline infusion via the long limb of the T-tube [9]. This paper reports the results obtained in 27 patients treated by this technique in a number of U.K. hospitals.
Patients and Methods
The group of patients treated consisted of 16 females and 11 males who had undergone cholecystectomy and exploration of the c o m m o n bile duct. The age of the patients varied from 27 to 92 years, with a mean of 60 years. The residual stones were diagnosed on the post-operative T-tube cholangiogram. Six patients had two or more residual stones. The radiological stone size varied from 3 to 15 mm, median 9mm.
289
The technique employed involved the administration of ceruletide (Farmitalia Carlo Erba) intravenously in a dose of 2 ng/kg/min in saline for 1 h as a constant infusion. Five minutes after the start of the ceruletide infusion, sterile isotonic saline was infused via a disposable manometry line through the external limb of the T-tube for a period of 1 h. The biliary pressure was momtored through the U-limb of the manometry line used to infuse saline in the common bile duct. Intraductal saline was administered at a rate which did not result in a significant rise in the biliary pressure. Three patients received two separate ceruletide/ductal saline infusion treatments. The procedure was covered with systemic antibiotics, the detads of which varied from hospital to hospital. The efficacy of the treatment was assessed by repeat T-tube cholangiography in all the patients.
Results
There were minor departures from the intended protocol. Thus, the mean dose of ceruletide administered to the patients in the study was 1.98 ng/kg/min (SD 0.80). The duration of saline infusion was 54.7 min (SD 14.3), and the amount of saline infused into the T-tube varied from 0.1 to 3.0 litres with a mean of 1.2 litres. Complete clearance was achieved in 9 patients (33%) after one treatment. In a further 4 patients, passage of some stones was documented but residual calculi were still present on the post-treatment cholangiogram. One of these patients achieved complete clearance after a further treatment with ceruletide and saline infusion 1 day later. The treatment was completely unsuccessful in 14 patients (Table 1). This TABLE 1 EFFICACY THERAPY
OF
CERULETIDE/SALINE
Result
No.
Complete clearance Partial clearance Failure
9 42 14
INFUSION
a Complete clearance in one patient after second treatment.
290
s. SADEK and A. CUSCHIERI
TABLE 2
TABLE 4
OUTCOME VS. RADIOLOGICAL STONE SIZE
SIDE EFFECTS OF TREATMENT
Size (mm)
No.
3-5 6-10 11-15
11 10 4
Clearance
Failure
complete
partial
3 3 3
2 2 0
6 5 1
7(2 = 3.5 (4 df); not significant.
na
Nausea/vomiting Abdominal pain/discomfort Diarrhoea Pyrexia Stone impaction
5 6 4 1 1
d 17 side effects in I0 patients.
included one patient in whom ampullary stone impaction occurred and required endoscopic sphincterotomy. Within the range of stone size e n c o u n t e r e d in the study, there was no correlation between a successful outcome and radiological stone size (Table 2). Details of the biliary pressure during saline infusion through the c o m m o n bile duct were available in 19 patients. The biliary pressure did not exceed 25 cm H20 during saline infusion in 7 patients. The treatment was successful in all these patients (complete in 5, partial in 2) whereas stone clearance was encountered in only 3 out of 12 patients in whom the biliary pressure exceeded 27 cm H 2 0 (Table 3). No correlation was found between passage of stones and flow rate of saline through the T-tube. The side effects of ceruletide t r e a t m e n t are outlined in Table 4. Colicky a b d o m i n a l pain was encountered in 6 patients, usually at the start of the saline infusion. F o u r of these patients achieved complete clearance of the ductai calculi. O t h e r side effects included nausea/vomiting in 5 and d i a r r h o e a in 4. The latter was only e n c o u n t e r e d in patients who received 1 litre or more of saline infusion into the c o m m o n bile duct. T r e a t m e n t had to be stopped p r e m a t u r e l y in one patient who d e v e l o p e d severe pain due to impac-
TABLE 3 OUTCOME VS. BILIARY PRESSURE DURING SALINE INFUSION IN 19 PATIENTS Pressure (em H20 )
No.
Clearance complete
partial
0-25 26-45
7 12
5 1
2 2
X2 = 9.9 (2df);P<0.01.
Side effect
Failure 0 9
tion of the stone in the ampulla of Vater. This patient required endoscopic sphincterotomy. All the other side effects were not severe and limited to the duration of treatment.
Discussion The results o b t a i n e d with ceruletide controlled saline infusion of the c o m m o n bile duct in this study compare very favourably with those of stone dissolution by the intraductal infusion of m o n o o c t a n o i n [10]. This treatment is unequivocally successful in 33% of patients and partially so in 13%. The results of the present ceruletide study are better than those reported following t r e a t m e n t with sodium cholate [11] or heparin solution [12], but they are u n d o u b t e d l y inferior to those o b t a i n e d by either endoscopic sphincterotomy or extraction via the T-tube tract. The ceruletide treatment is, however, completely non-invasive, does not require any special expertise and is easy to administer. F u r t h e r m o r e , it was not accompanied by any serious or life-threatening complications. Side effects were e n c o u n t e r e d in this study. They were short of duration and limited to the period of infusion. The abdominal pain and the d i a r r h o e a are due to the saline infusion into the c o m m o n bile duct, but the nausea and vomiting, which occurred in 18% of patients, a p p e a r to be direct side effects of ceruletide administration and we have e n c o u n t e r e d them when this p e p t i d e has been used in other clinical situations, such as paralytic ileus or pseudo-obstruction. W e would now r e c o m m e n d that the patients be p r e m e d i cared with an anti-emetic before the start of the ceruletide therapy.
CERULETIDE TREATMENT OF RETAINED DUCTAL CALCULI This study confirms the efficacy of ceruletide controlled ductal saline infusion in patients with retained ductai calculi, but a prospective controlled clinical trial is needed to confirm the beneficial effect of ceruletide over ductal saline infusion alone. Meantime, this treatment should be considered in patients with retained ductal calculi as a first-line measure. Its use may avoid the need for more invasive procedures such as endoscopic sphincterotomy or stone extraction via the T-tube tract.
Participating clinicians Mr. C. Mackie, Walton Hospital, Liverpool; Mr.
References 1 DenBesten L, Berci G. The current status of biliary tract surgery: An international study of 1072 consecutive patients. World J Surg 1986; 10:116-122. 2 Burhenne JJ. Nonoperative retained stone extraction. Am J Roentgenol 1973; 117: 388-399. 3 Yamakawa T. An improved choledocho-fiberscope and non-surgical removal of retained biliary calculi under direct visual control. Gastrointest Endosc 1976; 22: 160-165. 4 Cotton PB. Endoscopic management of bile duct stones: (Apples and oranges). Gut 1984; 25: 587-597. 5 Thistle JL, Carlson GL, Hofmann AF, et al. Monooctanoin, a dissolution agent for retained cholesterol bile duct stones: physical properties and clinical application. Gastroenterology 1980; 78: 1016-1022. 6 Hofmann AF, Schmack B, Thistle JL, Babayan VK. Clinical experience with monooctanoin for dissolution of bile duct stones. An uncontrolled multicentre trial. Dig Dis Sci
291
R. Crosbie, Arrow Park Hospital, Wirral; Mr. D. Brown, Derriford General Hospital, Plymouth; Mr. A.N. Hamlyn, Russells Hall Hospital, West Midlands; Mr. J.E. Hale, East Surrey Hospital, Surrey; Mr. G.R. MacLatchie, Hartlepool General Hospital, Hartlepool; Mr. Williams, Nottingham District Hospital, Nottingham; Mr. P.J. Pheils, Isle of T h a n e t District Hospital, Margate; Mr. W. Lloyd-Jones, Broadgreen Hospital Liverpool; Mr. T. Preston, Whiston Hospital, Prescot; Mr. M. Colmer, St. Helens Hospital, St. Helens; Mr. E.M. Macllrath, Royal Victoria Hospital, Belfast; Mr. A . G . Cox, Northwick Park Hospital, Middlesex; Dr. R. Mendelson, Royal Liverpool Hospital, Liverpool; Mr. M. Knight, St. James's Hospital, London.
1981; 26: 954-955. 7 Allen MJ, Borody TJ, Bugliosi TF, et al. Rapid dissolution of gallstones in humans using methyl tert-butyl ether. New Engl J Med 1985; 312: 217-220. 8 Ganzina F, Santamaria A. Caerulein (ceruletide). A review. Acta Gastroenterol Belg 1976; 39: 169-185. 9 Cuschieri A. Management of retained biliary calculi: relaxation of sphincter induced by ceruletide. Br Med J 1984; 289: 1582. 10 Palmer KR, Hofmann AF. Intraductal mono-octanoin for the direct dissolution of bile duct stones: experience in 343 patients. Gut 1986; 27: 196-202. 11 Lansford C, Mehta S, Kern F Jr. The treatment of retained stones in the common bile duct with sodium cholate infusion. Gut 1974; 15: 48-51. 12 Gardner B. Experience with the use of intracholedochal heparinized saline for the treatment of retained common duct stones. Ann Surg 1973; 240-244.