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Fortuitous discovery of common bile duct stones: Results of a conservative strategy
Gastroentérologie Clinique et Biologique (2008) 32, 408—412 Disponible en ligne sur www.sciencedirect.com
ORIGINAL ARTICLE
Fortuitous discovery of common bile duct stones: Results of a conservative strategy Lithiase de la voie biliaire principale de découverte fortuite : résultats d’une attitude conservatrice P. Balandraud a, N. Biance a, T. Peycru a, E. Tardat a, P.-M. Bonnet a, C. Cazeres a, J. Hardwigsen b,∗ a
Hôpital d’instruction des armées Laveran, 13013 Marseille, France Service de chirurgie générale et de transplantation hépatique, CHU la Conception, 147, boulevard Baille, 13005 Marseille, France
b
Available online 9 April 2008 Summary Objective. — The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy. Patients and methods. — Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken. Results. — Cholecystectomy was performed in 124 patients with symptomatic gallstones and no signs predictive of stones in the common bile duct. A stone was found fortuitously in the common bile duct in 12 patients. The control cholangiogram was normal in two of these patients on day two (16.7%) and in six others (50%) at the six-week control. All 12 patients remained free of symptoms suggesting the presence of a stone in the common duct. Presence of the drain had no impact on quality-of-life. Endoscopic extraction was finally performed for four patients (33.3%) to remove a stone from the common bile duct. Conclusion. — Early surgical or endoscopic extraction of stones in the common bile duct should not be undertaken systematically in asymptomatic patients. Spontaneous asymptomatic clearance of the common bile duct is observed in about half of patients. © 2008 Elsevier Masson SAS. All rights reserved. Résumé L’incidence de la lithiase de la voie biliaire principale de découverte fortuite est d’environ 5 %. Le but de cette étude était de déterminer la fréquence de la migration ∗
Corresponding author. E-mail address: [email protected] (J. Hardwigsen).
0399-8320/$ – see front matter © 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.gcb.2008.02.023
Fortuitous discovery of common bile duct stones
409
spontanée des calculs asymptomatiques de la voie biliaire principale découverts au moment de la cholécystectomie. Tous les patients traités par cholécystectomie pour lithiase symptomatique de la voie biliaire accessoire ont eu une cholangiographie peropératoire. En cas de découverte d’une image lacunaire de la voie biliaire principale, un drainage transcystique a été mis en place. Aucune extraction chirurgicale ou endoscopique systématique n’a été proposée initialement. Une cholangiographie de contrôle a été réalisée le deuxième jour puis au cours de la sixième semaine. En cas de calcul résiduel à la sixième semaine, une extraction endoscopique de principe a été proposée. Résultats. — Cent vingt-quatre patients ont été opérés d’une lithiase vésiculaire symptomatique sans signe prédictif de lithiase de la voie biliaire principale. Douze patients avaient une lithiase fortuite de la voie biliaire principale. Un drainage transcystique a été mis en place chez ces 12 patients. La cholangiographie de contrôle était normale chez deux patients (16,7 %) au deuxième jour et chez six autres (50 %) à la sixième semaine. Dans l’intervalle, aucun des patients n’a eu de symptôme en rapport avec la présence de calcul dans la voie biliaire principale. Aucun des patients n’a allégué une altération de sa qualité de vie liée à la présence du drain. Quatre patients ont finalement été traités par extraction endoscopique de principe (33,3 %). Conclusion. — L’extraction chirurgicale ou endoscopique précoce ne devrait pas être proposée systématiquement à tous les patients ayant une lithiase asymptomatique de la voie biliaire principale. L’expulsion spontanée et asymptomatique des calculs de la voie biliaire principale survient dans plus de la moitié des cas. © 2008 Elsevier Masson SAS. All rights reserved.
Introduction Debate continues concerning the appropriate strategy when a stone is found fortuitously in the common bile duct during cholecystectomy for a symptomatic gallbladder [1]. For many, the risk of a potentially life-threatening complication (acute pancreatitis or cholangitis) warrants systematic extraction of all stones in the common bile duct, whether symptomatic or not [2]. With adapted equipment and a welltrained team, this can be done during the same operation, but necessarily requires more time. Furthermore, both the endoscopic and the surgical method lengthen the hospital stay, possibly leading to organizational problems when cholesystectomy was scheduled as an outpatient procedure or within the framework of a very short hospitalization [3,4]. It is known that a certain number of the stones detected in the common bile duct will migrate spontaneously, and asymptomatically [5—8]. One recent monocentric study noted that the rate of asymptomatic clearance is more than 50% after simple transcystic drainage [5]. The purpose of this study was to determine whether this finding could be reproduced by a team of several operators using the same protocol.
Patients and methods All patients who underwent cholecystectomy in our unit between January 2004 and October 2005 for gallbladder stones were eligible for inclusion in this prospective study. After history taking and physical examination, preoperative explorations included laboratory tests (cell counts, liver battery) and hepatobiliary ultrasound. Patients presenting one or more signs predictive of lithiasis of the common bile duct — preoperative jaundice, acute pancreatitis, abnormal liver tests, dilatation of the common bile duct greater than 8 mm at ultrasound or visualization of a stone in the common bile duct [9] — were not retained for the study.
Transcystic intraoperative cholangiography was performed as part of the cholecystectomy procedure, with two objectives: detection of stones in the common bile duct and search for anatomic anomalies of the biliary tree [10]. This cholangiography (opacification with Hexabrix® diluted 50%) was a two-phase procedure: first thin slice images to detect stones in the common bile duct, then a complete cholangiogram to rule out any biliary wound. Two senior surgeons (PB and ET) interpreted the opacification images. If the transcystic intraoperative cholangiography revealed a filling defect in the common bile duct, a transcystic drain (escat or pedinielli, Porges® ) was inserted, with no other surgical maneuver. A control transcystic cholangiography was performed on the second postoperative day. The drain was temporarily clamped at patient discharge. Patients were given detailed information about what to do in the event of pain, shivers or fever, pruritis or jaundice, and were shown how to open the drain for gravity drainage before emergency consultation. If the control cholangiography performed on the second postoperative day was considered normal, the drain was withdrawn the second postoperative week at an outpatient clinic. If the cholangiography was considered abnormal, follow-up included control visits (physical examination and laboratory tests) during the third and sixth postoperative weeks. A transcystic cholangiography was performed systematically at the sixth-week visit. If the common bile duct lithiasis persisted at six weeks, endoscopic extraction of the main stone or stones was proposed. All patients were informed about the study protocol and gave their oral consent for participation. Before patient discharge, the investigators checked carefully that the patient was well aware of the maneuvers to be performed should an emergency situation arise.
Results During the study period, 161 patients underwent laparoscopic cholecystectomy for symptomatic gallbladder stones. Among these 161 patients, 124 did not have any sign predictive of lithiasis of the common bile duct and were thus included in this study. Mean age was 55 years (range 37—75 years); the M/F sex ratio was 0.57. Eighty-one
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Table 1 Characteristic features of 12 patients with asymptomatic stones in the common bile duct revealed by intraoperative cholangiography. Caractéristiques des 12 patients porteurs d’une lithiase de la voie biliaire principale asymptomatique révélée par la cholangiographie peropératoire.
Age, years (range) Male/female Median operative time, minutes (range) Median hospital stay, days (range) Indications
Patients with a stone in the common bile duct n = 12
Other patients n = 112
63 (21—85) 5/7 85 (70—140) 4 (3—13) Acute cholecystitis (n = 4) Hepatic colic (n = 8)
53 (22—88) 38/74 55 (35—160) 3 (1—21) Acute cholecystitis (n = 38) Hepatic colic (n = 73) Polyp (n = 1)
patients presented hepatic colic, 42 acute cholecystitis, and one a gallbladder polyp (Table 1). Conversion to laparotomy was required for seven of the 124 patients (5.8%). Transcystic intraoperative cholangiography was performed successfully in 90.3% of patients. The main causes of failure were small-caliber cystic duct (n = 9) and pediculitis (n = 3). A fortuitous diagnosis of lithiasis of the common bile duct was established in 12 patients (9.7% of the patients undergoing cholecystectomy without signs predictive of lithiasis of the common bile duct). The time course of the liver tests from these 12 patients is presented in Table 2. All 12 patients who had a fortuitously discovered stone in the common bile duct agreed to the planned schedule. The control cholangiography performed on the second postoperative day was considered normal in two patients (16.7%). The control cholangiography performed during the sixth postoperative week was considered normal in six patients (50%). The four other patients were symptom-free at six weeks and underwent endoscopic extraction of the stone(s) in the common bile duct (Figs. 1 and 2). The median hospital stay for these 12 patients was four days; the median hospital stay for the other 112 patients was three days. The median cumulative hospital stay for the four patients who underwent endoscopic retrograde cholangiopancreatography (including the stay for cholecystecomy and for the stay for endoscopic retrograde cholangiopancreatography) was six days. The largest stone which migrated measured 8 mm. The largest proportion of the stones which migrated measured 5 mm. Residual stones at six weeks measured less than 5 mm in two patients (a single stone for one patient, more than 20 stones for the other). No stones could be individualized in the two other patients whose common bile duct contained sludge. All 12 patients remained symptom-free during the six-week postoperative follow-up; none of them opened their drain in an emergency situation and none of them complained about having the drain.
Figure 1 Postoperative cholangiogram, day 2. Cholangiographie de contrôle au deuxième jour postopératoire.
Discussion Excepting cases where the clinical situation enables prediction of stones in the common bile before cholecystectomy, fortuitous discovery of a filling defect in the common duct
Table 2 Time course of liver tests in 12 patients with stones in the common bile duct. Évolution du bilan hépatique des 12 patients porteurs d’une lithiase de la voie biliaire principale. Median (range)
2nd postoperative day
6th week
Preoperative endoscopic retrograde cholangiopancreatography (n = 4)
Alkaline phosphatases (IU/L) Gamma glutamyltransferase (IU/L) Total bilirubin (mol/L) Serum lipase (IU/L)
61 61 7 38
68 48 6 41
71 53 9 43
(56—98) (12—83) (5—16) (32—112)
(53—121) (29—96) (5—13) (34—135)
(55—126) (43—123) (5—12) (34—127)
Fortuitous discovery of common bile duct stones
Figure 2 Cholangiogram at six weeks: clearance of the common bile duct. Cholangiographie à six semaines : vacuité de la voie biliaire principale.
during intraoperative cholangiography raises the question of the appropriate management strategy. First an artifact effect must be ruled out. Fortuitous discovery of a stone in the common bile duct is reported in 4 to 6% of all cholecystectomy procedures [5,11]. About 90,000 cholecystectomy procedures are preformed annually in France [12] (about 400,000 in the United States [13]), mostly for symptomatic gallstones with no sign predictive of lithiasis of the common duct. If one considers that about half of the surgeons perform an intraoperative cholangiography systematically and that more than 5% of these procedures yield a fortuitous diagnosis of a stone in the common duct, this situation would occur more than 2000 times a year in France (10,000 in the United States). When a stone is discovered, surgical extraction during the same procedure can be proposed, either via a transcystic approach or by choledochotomy [14,15]. This significantly lengthens the operative time, and when difficult, may require conversion to laparotomy [16—18]. For Lauter et Froines [18], the mean operative time for cholecystectomy with transcystic extraction of a stone in the common duct was 159 min; the time for extraction via choledochotomy was 255 min. The caliber of a common duct with a stone is often small, making choledochotomy a delicate task with a high risk of postoperative stenosis. Nathanson et al. [19] reported that more than 2% of the procedures led to postoperative stenosis of the common bile duct. The alternative would be ‘‘systematic’’ endoscopic extraction. The main drawbacks of this option are the associated risks of early complications, sometimes affecting more than 10% of patients [20], such as severe acute pancreatitis, reported in nearly 1% of patients [20,21]. Long-term complications include reflux cholangitis with backflow con-
411 tamination of the bile and formation of pigment stones. These late complications are observed in nearly 10% of patients [22—24]. The endoscopic method is often performed during a second operative phase requiring a second general anesthesia and a longer hospital stay. Endoscopic extraction, like surgical removal, is more difficult when the common duct is small. These two empiric options do not take into consideration the possibility of false positives [10] and the fact that duct clearance can occur spontaneously [5—8,11,25]. Our protocol was established following the work reported by Collins et al. [5] who found that the cholangiogram returned to normal in 52% of patients (24 of 46 patients) after transcystic drainage for six weeks. These authors considered that spontaneous clearance was authentic in 12 patients, while for the 12 others (with normal cholangiography on the second day), the transcystic intraoperative cholangiography had yielded a false positive. The rate of spontaneous clearance was thus 26% and surgical exploration or endoscopic extraction was avoided in 52% of patients. In that series, there was no correlation between the size or number of stones and spontaneous clearance. The authors observed spontaneous ductal clearance for stones measuring 15 mm while other stones measuring 5 mm were still in the common bile duct at the sixth week. In our series, we considered that the intraoperative opacification gave a false positive for the two patients whose day-2 cholangiogram was normal [26,27]. This gave a falsepositive rate of 16.7%. Our strategy allowed us to avoid surgical exploration of the common bile duct in eight of 12 patients (66.7%), and postoperative endoscopic stone extraction in six of 12 (50%). As also reported by Collins et al., we did not find any link between the size or number of stones and spontaneous clearance. Spontaneous clearance has been reported by many authors in 16% to 75% of patients [6—8,11,25]. Hainsworth et al. [25] compared the pre- and postoperative endoscopic retrograde cholangiopancreatograms. In their postoperative group, the rate of spontaneous clearance was 75% (8/12 patients). Ryberg et al. [7] studied patients who had an abnormal cholangiogram who did not have to have an exploration of the common bile duct. They found spontaneous clearance in 14 to 64% of patients depending on the signs used to define an abnormal transcystic intraoperative cholangiogram: absence of stone passage into the duodenum, doubtful or univocal image of intraductal lithiasis. Tranter et Thompson [8] reported that spontaneous clearance could be observed in patients with preoperative signs predictive of bile duct stones. They analyzed the records of 1000 consecutive patients after cholecystectomy and found that preoperatively, 532 had signs predictive of a stone in the common duct. At the time of surgery, only 142 patients had bile duct stones. They concluded that spontaneous clearance had occurred in 390 patients (73% of the stones). Elevated liver or pancreatic enzymes (poorly specific signs) were used as preoperative signs suggestive of common bile duct stones. In 1956, Fitzgibbons et al. [6] were the first to propose transcystic drainage for patients with a fortuitously discovered lithiasis of the common bile duct, after observing spontaneous clearance in 11 out of 24 cases. O’Sullivan
412 instituted transcystic drainage as a standard protocol and published the first prospective series [5,11]. In our clinical practice, we consider that the main objective for transcystic drainage is to avoid excessive pressure in the common bile duct. The transcystic drain can also be used for the control cholangiography. This is one of the most sensitive and most specific explorations available for the diagnosis of residual stones in the common bile duct [26]. It can easily be performed in an outpatient clinic. Furthermore, if endoscopic extraction should be required, the transcystic drain facilitates the procedure by allowing transpapillary descent of the guidewire. This protocol has some drawbacks related to the drain and the dressing as well as the need for good patient comprehension should an emergency maneuver be required. The best duration for the drainage remains to be determined. We opted for six weeks for better comparison with earlier reports.
Conclusion Most asymptomatic common bile duct stones have a favorable natural history. Fortuitous discovery during a cholecystectomy procedure should not lead to systematic surgical or endoscopic extraction. The exact characteristics of common bile duct lithitasis enabling this favorable course remain to be determined.
References [1] Millat B, Guillon F, Borie F. Surgical treatment of lithiasis of the common bile duct. Gastroenterol Clin Biol 1998;22(Suppl. 5):B23—9. [2] Gerber A. A requiem for the routine operative cholangiogram. Surg Gynecol Obstet 1986;163:363—4. [3] Proske JM, Dagher I, Revitea C, Carloni A, Beauthier V, Labaille T, et al. Day-case laparoscopic cholecystectomy: results of 211 consecutive patients. Gastroenterol Clin Biol 2007;31:421—4. [4] Bona S, Monzani R, Fumagalli Romario U, Zago M, Mariani D, Rosati R. Outpatient laparoscopic cholecystectomy: a prospective study on 250 patients. Gastroenterol Clin Biol 2007;31:1010—5. [5] Collins C, Maguire D, Ireland A, Fitzgerald E, O’Sullivan GC. A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited. Ann Surg 2004;239:28—33. [6] Fitzgibbons Jr RJ, Ryberg AA, Ulualp KM, Nguyen NX, Litke BS, Camps J, et al. An alternative technique for treatment of choledocholithiasis found at laparoscopic cholecystectomy. Arch Surg 1995;130:638—42. [7] Ryberg AA, Fitzgibbons Jr RJ, Tseng A, Maffi TR, Burr LJ, Doris PE. Abnormal cholangiograms during laparoscopic cholecystectomy. Is treatment always necessary ? Surg Endosc 1997;11:456—9. [8] Tranter SE, Thompson MH. Spontaneous passage of bile duct stones: frequency of occurrence and relation to clinical presentation. Ann R Coll Surg Engl 2003;85:174—7. [9] Abboud P, Malet P, Berlin J, Staroscik R, Cabana M, Clark J, et al. Predictors of common bile duct stones prior to cholecystectomy: a meta-analysis. Gastrointest Endosc 1996;44:450—7.
P. Balandraud et al. [10] Bouillot J, Fernandez F, Dehni N, Salah S, al Hajj G, Badawy A, et al. Intraoperative systematic cholangiography in celioscopic cholecystectomy. Gastroenterol Clin Biol 1995;19: 287—90. [11] O’Donovan AN, O’Sullivan G, Ireland A, FitzGerald E. Prospective trial of the role of fine bore intubation of the cystic duct at the time of operative cholangiography. J Am Coll Surg 1997;184:262—4. [12] Bartoli E, Capron JP. Epidemiology and natural history of cholelithiasis. Rev Prat 2000;50:2112—6. [13] Kozak LJ, Owings MF, Hall MJ. National Hospital Discharge Survey: 2002 annual summary with detailed diagnosis and procedure data. Vital Health Stat 2005;13(158):1—199. [14] Millat B, Atger J, Deleuze A, Briandet H, Fingerhut A, Guillon F, et al. Laparoscopic treatment for choledocholithiasis: a prospective evaluation in 247 consecutive unselected patients. Hepatogastroenterology 1997;44:28—34. [15] Berthou JC, Drouard F, Charbonneau P, Moussalier K. Evaluation of laparoscopic management of common bile duct stones in 220 patients. Surg Endosc 1998;12:16—22. [16] Petelin J. Laparoscopic approach to common duct pathology. Am J Surg 1993;165:487—91. [17] Hunter J. Laparoscopic transcystic common bile duct exploration. Am J Surg 1992;163:53—6. [18] Lauter DM, Froines EJ. Laparoscopic common duct exploration in the management of choledocholithiasis. Am J Surg 2000;179:372—4. [19] Nathanson LK, O’Rourke NA, Martin IJ, Fielding GA, Cowen AE, Roberts RK, et al. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg 2005;242:188—92. [20] Suc B, Escat J, Cherqui D, Fourtanier G, Hay JM, Fingerhut A, et al. Surgery vs endoscopy as primary treatment in symptomatic patients with suspected common bile duct stones: a multicenter randomized trial. French Associations for Surgical Research. Arch Surg 1998;133:702—8. [21] Cheng CL, Sherman S, Watkins JL, Barnett J, Freeman M, Geenen J, et al. Risk factors for post-ERCP pancreatitis: a prospective multicenter study. Am J Gastroenterol 2006;101:139—47. [22] Sugiyama M, Atomi Y. Follow-up of more than 10 years after endoscopic sphincterotomy for choledocholithiasis in young patients. Br J Surg 1998;85:917—21. [23] Makinen AM, Frey T, Turjanmaa V, Harmoinen A, Sand J, Nordback I. Long-term effects of transduodenal sphincterotomy: symptoms and hepatobiliary function. Hepatogastroenterology 1998;45:1436—41. [24] Sandstad O, Osnes T, Skar V, Urdal P, Osnes M. Common bile duct stones are mainly brown and associated with duodenal diverticula. Gut 1994;35:1464—7. [25] Hainsworth P, Rhodes M, Gompertz R, Armstrong C, Lennard T. Imaging of the common bile duct in patients undergoing laparoscopic cholecystectomy. Gut 1994;35: 991—5. [26] Montariol T, Msika S, Charlier A, Rey C, Bataille N, Hay JM, et al. Diagnosis of asymptomatic common bile duct stones: preoperative endoscopic ultrasonography versus intraoperative cholangiography– a multicenter, prospective controlled study. French Associations for Surgical Research. Surgery 1998;124:6—13. [27] Caroll B, Phillips E, Rosenthal R, Gleischman S, Bray J. One hundred consecutive laparoscopic cholangiograms. Results and conclusions. Surg Endosc 1996;9:319—23.
ORIGINAL ARTICLE
Fortuitous discovery of common bile duct stones: Results of a conservative strategy Lithiase de la voie biliaire principale de découverte fortuite : résultats d’une attitude conservatrice P. Balandraud a, N. Biance a, T. Peycru a, E. Tardat a, P.-M. Bonnet a, C. Cazeres a, J. Hardwigsen b,∗ a
Hôpital d’instruction des armées Laveran, 13013 Marseille, France Service de chirurgie générale et de transplantation hépatique, CHU la Conception, 147, boulevard Baille, 13005 Marseille, France
b
Available online 9 April 2008 Summary Objective. — The incidence of fortuitously discovered stones in the common bile duct is about 5%. The purpose of this study was to determine the rate of spontaneous clearance of asymptomatic stones in the common bile duct discovered fortuitously during cholecystectomy. Patients and methods. — Intraoperative cholangiography was performed in all patients undergoing cholecystectomy for symptomatic gallbladder stones. If a filling defect of the common bile duct was discovered, a transcystic drain was inserted. Surgical or endoscopic extraction was not proposed initially. A control cholangiogram was performed on the second postoperative day then during the sixth postoperative week. If a stone persisted at the sixth week, endoscopic extraction was undertaken. Results. — Cholecystectomy was performed in 124 patients with symptomatic gallstones and no signs predictive of stones in the common bile duct. A stone was found fortuitously in the common bile duct in 12 patients. The control cholangiogram was normal in two of these patients on day two (16.7%) and in six others (50%) at the six-week control. All 12 patients remained free of symptoms suggesting the presence of a stone in the common duct. Presence of the drain had no impact on quality-of-life. Endoscopic extraction was finally performed for four patients (33.3%) to remove a stone from the common bile duct. Conclusion. — Early surgical or endoscopic extraction of stones in the common bile duct should not be undertaken systematically in asymptomatic patients. Spontaneous asymptomatic clearance of the common bile duct is observed in about half of patients. © 2008 Elsevier Masson SAS. All rights reserved. Résumé L’incidence de la lithiase de la voie biliaire principale de découverte fortuite est d’environ 5 %. Le but de cette étude était de déterminer la fréquence de la migration ∗
Corresponding author. E-mail address: [email protected] (J. Hardwigsen).
0399-8320/$ – see front matter © 2008 Elsevier Masson SAS. All rights reserved. doi:10.1016/j.gcb.2008.02.023
Fortuitous discovery of common bile duct stones
409
spontanée des calculs asymptomatiques de la voie biliaire principale découverts au moment de la cholécystectomie. Tous les patients traités par cholécystectomie pour lithiase symptomatique de la voie biliaire accessoire ont eu une cholangiographie peropératoire. En cas de découverte d’une image lacunaire de la voie biliaire principale, un drainage transcystique a été mis en place. Aucune extraction chirurgicale ou endoscopique systématique n’a été proposée initialement. Une cholangiographie de contrôle a été réalisée le deuxième jour puis au cours de la sixième semaine. En cas de calcul résiduel à la sixième semaine, une extraction endoscopique de principe a été proposée. Résultats. — Cent vingt-quatre patients ont été opérés d’une lithiase vésiculaire symptomatique sans signe prédictif de lithiase de la voie biliaire principale. Douze patients avaient une lithiase fortuite de la voie biliaire principale. Un drainage transcystique a été mis en place chez ces 12 patients. La cholangiographie de contrôle était normale chez deux patients (16,7 %) au deuxième jour et chez six autres (50 %) à la sixième semaine. Dans l’intervalle, aucun des patients n’a eu de symptôme en rapport avec la présence de calcul dans la voie biliaire principale. Aucun des patients n’a allégué une altération de sa qualité de vie liée à la présence du drain. Quatre patients ont finalement été traités par extraction endoscopique de principe (33,3 %). Conclusion. — L’extraction chirurgicale ou endoscopique précoce ne devrait pas être proposée systématiquement à tous les patients ayant une lithiase asymptomatique de la voie biliaire principale. L’expulsion spontanée et asymptomatique des calculs de la voie biliaire principale survient dans plus de la moitié des cas. © 2008 Elsevier Masson SAS. All rights reserved.
Introduction Debate continues concerning the appropriate strategy when a stone is found fortuitously in the common bile duct during cholecystectomy for a symptomatic gallbladder [1]. For many, the risk of a potentially life-threatening complication (acute pancreatitis or cholangitis) warrants systematic extraction of all stones in the common bile duct, whether symptomatic or not [2]. With adapted equipment and a welltrained team, this can be done during the same operation, but necessarily requires more time. Furthermore, both the endoscopic and the surgical method lengthen the hospital stay, possibly leading to organizational problems when cholesystectomy was scheduled as an outpatient procedure or within the framework of a very short hospitalization [3,4]. It is known that a certain number of the stones detected in the common bile duct will migrate spontaneously, and asymptomatically [5—8]. One recent monocentric study noted that the rate of asymptomatic clearance is more than 50% after simple transcystic drainage [5]. The purpose of this study was to determine whether this finding could be reproduced by a team of several operators using the same protocol.
Patients and methods All patients who underwent cholecystectomy in our unit between January 2004 and October 2005 for gallbladder stones were eligible for inclusion in this prospective study. After history taking and physical examination, preoperative explorations included laboratory tests (cell counts, liver battery) and hepatobiliary ultrasound. Patients presenting one or more signs predictive of lithiasis of the common bile duct — preoperative jaundice, acute pancreatitis, abnormal liver tests, dilatation of the common bile duct greater than 8 mm at ultrasound or visualization of a stone in the common bile duct [9] — were not retained for the study.
Transcystic intraoperative cholangiography was performed as part of the cholecystectomy procedure, with two objectives: detection of stones in the common bile duct and search for anatomic anomalies of the biliary tree [10]. This cholangiography (opacification with Hexabrix® diluted 50%) was a two-phase procedure: first thin slice images to detect stones in the common bile duct, then a complete cholangiogram to rule out any biliary wound. Two senior surgeons (PB and ET) interpreted the opacification images. If the transcystic intraoperative cholangiography revealed a filling defect in the common bile duct, a transcystic drain (escat or pedinielli, Porges® ) was inserted, with no other surgical maneuver. A control transcystic cholangiography was performed on the second postoperative day. The drain was temporarily clamped at patient discharge. Patients were given detailed information about what to do in the event of pain, shivers or fever, pruritis or jaundice, and were shown how to open the drain for gravity drainage before emergency consultation. If the control cholangiography performed on the second postoperative day was considered normal, the drain was withdrawn the second postoperative week at an outpatient clinic. If the cholangiography was considered abnormal, follow-up included control visits (physical examination and laboratory tests) during the third and sixth postoperative weeks. A transcystic cholangiography was performed systematically at the sixth-week visit. If the common bile duct lithiasis persisted at six weeks, endoscopic extraction of the main stone or stones was proposed. All patients were informed about the study protocol and gave their oral consent for participation. Before patient discharge, the investigators checked carefully that the patient was well aware of the maneuvers to be performed should an emergency situation arise.
Results During the study period, 161 patients underwent laparoscopic cholecystectomy for symptomatic gallbladder stones. Among these 161 patients, 124 did not have any sign predictive of lithiasis of the common bile duct and were thus included in this study. Mean age was 55 years (range 37—75 years); the M/F sex ratio was 0.57. Eighty-one
410
P. Balandraud et al.
Table 1 Characteristic features of 12 patients with asymptomatic stones in the common bile duct revealed by intraoperative cholangiography. Caractéristiques des 12 patients porteurs d’une lithiase de la voie biliaire principale asymptomatique révélée par la cholangiographie peropératoire.
Age, years (range) Male/female Median operative time, minutes (range) Median hospital stay, days (range) Indications
Patients with a stone in the common bile duct n = 12
Other patients n = 112
63 (21—85) 5/7 85 (70—140) 4 (3—13) Acute cholecystitis (n = 4) Hepatic colic (n = 8)
53 (22—88) 38/74 55 (35—160) 3 (1—21) Acute cholecystitis (n = 38) Hepatic colic (n = 73) Polyp (n = 1)
patients presented hepatic colic, 42 acute cholecystitis, and one a gallbladder polyp (Table 1). Conversion to laparotomy was required for seven of the 124 patients (5.8%). Transcystic intraoperative cholangiography was performed successfully in 90.3% of patients. The main causes of failure were small-caliber cystic duct (n = 9) and pediculitis (n = 3). A fortuitous diagnosis of lithiasis of the common bile duct was established in 12 patients (9.7% of the patients undergoing cholecystectomy without signs predictive of lithiasis of the common bile duct). The time course of the liver tests from these 12 patients is presented in Table 2. All 12 patients who had a fortuitously discovered stone in the common bile duct agreed to the planned schedule. The control cholangiography performed on the second postoperative day was considered normal in two patients (16.7%). The control cholangiography performed during the sixth postoperative week was considered normal in six patients (50%). The four other patients were symptom-free at six weeks and underwent endoscopic extraction of the stone(s) in the common bile duct (Figs. 1 and 2). The median hospital stay for these 12 patients was four days; the median hospital stay for the other 112 patients was three days. The median cumulative hospital stay for the four patients who underwent endoscopic retrograde cholangiopancreatography (including the stay for cholecystecomy and for the stay for endoscopic retrograde cholangiopancreatography) was six days. The largest stone which migrated measured 8 mm. The largest proportion of the stones which migrated measured 5 mm. Residual stones at six weeks measured less than 5 mm in two patients (a single stone for one patient, more than 20 stones for the other). No stones could be individualized in the two other patients whose common bile duct contained sludge. All 12 patients remained symptom-free during the six-week postoperative follow-up; none of them opened their drain in an emergency situation and none of them complained about having the drain.
Figure 1 Postoperative cholangiogram, day 2. Cholangiographie de contrôle au deuxième jour postopératoire.
Discussion Excepting cases where the clinical situation enables prediction of stones in the common bile before cholecystectomy, fortuitous discovery of a filling defect in the common duct
Table 2 Time course of liver tests in 12 patients with stones in the common bile duct. Évolution du bilan hépatique des 12 patients porteurs d’une lithiase de la voie biliaire principale. Median (range)
2nd postoperative day
6th week
Preoperative endoscopic retrograde cholangiopancreatography (n = 4)
Alkaline phosphatases (IU/L) Gamma glutamyltransferase (IU/L) Total bilirubin (mol/L) Serum lipase (IU/L)
61 61 7 38
68 48 6 41
71 53 9 43
(56—98) (12—83) (5—16) (32—112)
(53—121) (29—96) (5—13) (34—135)
(55—126) (43—123) (5—12) (34—127)
Fortuitous discovery of common bile duct stones
Figure 2 Cholangiogram at six weeks: clearance of the common bile duct. Cholangiographie à six semaines : vacuité de la voie biliaire principale.
during intraoperative cholangiography raises the question of the appropriate management strategy. First an artifact effect must be ruled out. Fortuitous discovery of a stone in the common bile duct is reported in 4 to 6% of all cholecystectomy procedures [5,11]. About 90,000 cholecystectomy procedures are preformed annually in France [12] (about 400,000 in the United States [13]), mostly for symptomatic gallstones with no sign predictive of lithiasis of the common duct. If one considers that about half of the surgeons perform an intraoperative cholangiography systematically and that more than 5% of these procedures yield a fortuitous diagnosis of a stone in the common duct, this situation would occur more than 2000 times a year in France (10,000 in the United States). When a stone is discovered, surgical extraction during the same procedure can be proposed, either via a transcystic approach or by choledochotomy [14,15]. This significantly lengthens the operative time, and when difficult, may require conversion to laparotomy [16—18]. For Lauter et Froines [18], the mean operative time for cholecystectomy with transcystic extraction of a stone in the common duct was 159 min; the time for extraction via choledochotomy was 255 min. The caliber of a common duct with a stone is often small, making choledochotomy a delicate task with a high risk of postoperative stenosis. Nathanson et al. [19] reported that more than 2% of the procedures led to postoperative stenosis of the common bile duct. The alternative would be ‘‘systematic’’ endoscopic extraction. The main drawbacks of this option are the associated risks of early complications, sometimes affecting more than 10% of patients [20], such as severe acute pancreatitis, reported in nearly 1% of patients [20,21]. Long-term complications include reflux cholangitis with backflow con-
411 tamination of the bile and formation of pigment stones. These late complications are observed in nearly 10% of patients [22—24]. The endoscopic method is often performed during a second operative phase requiring a second general anesthesia and a longer hospital stay. Endoscopic extraction, like surgical removal, is more difficult when the common duct is small. These two empiric options do not take into consideration the possibility of false positives [10] and the fact that duct clearance can occur spontaneously [5—8,11,25]. Our protocol was established following the work reported by Collins et al. [5] who found that the cholangiogram returned to normal in 52% of patients (24 of 46 patients) after transcystic drainage for six weeks. These authors considered that spontaneous clearance was authentic in 12 patients, while for the 12 others (with normal cholangiography on the second day), the transcystic intraoperative cholangiography had yielded a false positive. The rate of spontaneous clearance was thus 26% and surgical exploration or endoscopic extraction was avoided in 52% of patients. In that series, there was no correlation between the size or number of stones and spontaneous clearance. The authors observed spontaneous ductal clearance for stones measuring 15 mm while other stones measuring 5 mm were still in the common bile duct at the sixth week. In our series, we considered that the intraoperative opacification gave a false positive for the two patients whose day-2 cholangiogram was normal [26,27]. This gave a falsepositive rate of 16.7%. Our strategy allowed us to avoid surgical exploration of the common bile duct in eight of 12 patients (66.7%), and postoperative endoscopic stone extraction in six of 12 (50%). As also reported by Collins et al., we did not find any link between the size or number of stones and spontaneous clearance. Spontaneous clearance has been reported by many authors in 16% to 75% of patients [6—8,11,25]. Hainsworth et al. [25] compared the pre- and postoperative endoscopic retrograde cholangiopancreatograms. In their postoperative group, the rate of spontaneous clearance was 75% (8/12 patients). Ryberg et al. [7] studied patients who had an abnormal cholangiogram who did not have to have an exploration of the common bile duct. They found spontaneous clearance in 14 to 64% of patients depending on the signs used to define an abnormal transcystic intraoperative cholangiogram: absence of stone passage into the duodenum, doubtful or univocal image of intraductal lithiasis. Tranter et Thompson [8] reported that spontaneous clearance could be observed in patients with preoperative signs predictive of bile duct stones. They analyzed the records of 1000 consecutive patients after cholecystectomy and found that preoperatively, 532 had signs predictive of a stone in the common duct. At the time of surgery, only 142 patients had bile duct stones. They concluded that spontaneous clearance had occurred in 390 patients (73% of the stones). Elevated liver or pancreatic enzymes (poorly specific signs) were used as preoperative signs suggestive of common bile duct stones. In 1956, Fitzgibbons et al. [6] were the first to propose transcystic drainage for patients with a fortuitously discovered lithiasis of the common bile duct, after observing spontaneous clearance in 11 out of 24 cases. O’Sullivan
412 instituted transcystic drainage as a standard protocol and published the first prospective series [5,11]. In our clinical practice, we consider that the main objective for transcystic drainage is to avoid excessive pressure in the common bile duct. The transcystic drain can also be used for the control cholangiography. This is one of the most sensitive and most specific explorations available for the diagnosis of residual stones in the common bile duct [26]. It can easily be performed in an outpatient clinic. Furthermore, if endoscopic extraction should be required, the transcystic drain facilitates the procedure by allowing transpapillary descent of the guidewire. This protocol has some drawbacks related to the drain and the dressing as well as the need for good patient comprehension should an emergency maneuver be required. The best duration for the drainage remains to be determined. We opted for six weeks for better comparison with earlier reports.
Conclusion Most asymptomatic common bile duct stones have a favorable natural history. Fortuitous discovery during a cholecystectomy procedure should not lead to systematic surgical or endoscopic extraction. The exact characteristics of common bile duct lithitasis enabling this favorable course remain to be determined.
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