- Email: [email protected]
Removal of the elusive common duct stone
Removal
of the Elusive Common
Duct Stone
S.L. BUKANZ, M.D. AND H. H. SHAH, M.D., New York, New York This method has proved effective in many cases when all other methods have been unsuccessful [l-3]. On one occasion, an impacted stone in the ampulla of Vater could be palpated through the duodenum. It defied removal by all other methods but yielded to suction on the third attempt. Duodenostomy was thus avoided. A case in point is that of a thirty year old white woman who was operated on at New York Polyclinic Hospital on May 11, 1964 far chronic cholecystitis with cholelithiasis. A cholecystogram had revealed a gallbladder filled with many small faceted stones. There was no history or evidence of jaundice. The bilirubin and alkaline phosphatase were within the normal range. However, the patient had stated that the urine had been darker than normal for several days since her last attack and a trace of bile had been found in the urine. All other physical and laboratory examinations were negative for abnormalities. Exploration revealed a chronically diseased gallbladder filled with stones and a large cystic duct entering a dilated common duct. Many stones could be palpated within the cornmolt, duct. Extreme care was immediately taken ti prevent more stones from entering the common duct by clamping off the ampulla of the gall bladder. The cystic duct was then isolated and tied in continuity. The common duct was then opened and thirteen faceted stones of all sizes were removed by irrigation. At the end of the irrigation, no further stones could be palpated and the surgeon and his assistant believed that there were probably none left. Before taking a cholangiogram, it was decided to use the suction technic previously described herein. The
From the Department of Surgery, New York Polyclinic Hospital, New York, New York.
HE METHOD described herein is a very old
T one and has probably
been used by many. In discussing its excellent results with colleagues, however, I was surprised to note that it was used very infrequently. It is therefore being presented in detail as a review, and I am sure it will prove most valuable in the removal of elusive stones in the common duct, particularly those which are in the hepatic ducts. The method consists of attaching strong suction to the proximal cut end of a No. 16 catheter or larger using a medicine dropper as a connecting rod to the suction tubing. The distal end of the catheter is fashioned into a small cup. With the suction blocked, this end is inserted into the common duct and its tributaries. Suction is released suddenly and the stone, if present, is frequently drawn into the cup. (Fig. I.)
FIG. 1. The successful removal from the hepatic ducts.
of unsuspected stones
598
American Journal of Surgery
Common suction end was repeatedly introduced into the left and right hepatic ducts? and to our surprise it produced four additional stones. These unquestionably would never have been secured by any other method. They either were forced up there by our irrigation or were present before the operation [4,5]. After their removal, a cholangiogram was taken on the operating table and revealed no stones. The dye entered the duodenum with great ease. SUMMARY
A simple method for the removal of the elusive common duct stone is presented as a reminder of its effectiveness.
Duct
Stone
599 REFERENCES
1. COLCOCK,B. P. An Additional Aid in Exploration of the Common Bile Duct. Lahey Clin. Bull., 10: 73, 1956. 2. GLESN, F. Common duct exploration for stones. Surg., Gynec. & Obst., 95: 431, 1952. 3. PAYNE, J. R. and FIRME, C. xi. Problem of overlooked common duct stone. -4~. Surgean, 20: 1171, 1954. 4. COLCOCK, B. P. and LIDDLE, H. ‘1;. Common bile duct stones. n7ervEngland J. Med., 258: 264, 1958. 5. SINGLETON,A. O., JR. and COLEMAN, J. L. Residual common duct calculi. Ann. Surg., 143: 619, 1956. ADDITIONAL REFERENCES
NOT CITED IN TEXT
COBO, A., HALL, R. C., and TORRES, E. Intrahepatic calculi. Arch. of Surg., 89: 936, 1964. HUGHES, E. S. R. Recurrent and residual stones in common bile duct. &it. J. Surg., 43: 198, 1956.
of the Elusive Common
Duct Stone
S.L. BUKANZ, M.D. AND H. H. SHAH, M.D., New York, New York This method has proved effective in many cases when all other methods have been unsuccessful [l-3]. On one occasion, an impacted stone in the ampulla of Vater could be palpated through the duodenum. It defied removal by all other methods but yielded to suction on the third attempt. Duodenostomy was thus avoided. A case in point is that of a thirty year old white woman who was operated on at New York Polyclinic Hospital on May 11, 1964 far chronic cholecystitis with cholelithiasis. A cholecystogram had revealed a gallbladder filled with many small faceted stones. There was no history or evidence of jaundice. The bilirubin and alkaline phosphatase were within the normal range. However, the patient had stated that the urine had been darker than normal for several days since her last attack and a trace of bile had been found in the urine. All other physical and laboratory examinations were negative for abnormalities. Exploration revealed a chronically diseased gallbladder filled with stones and a large cystic duct entering a dilated common duct. Many stones could be palpated within the cornmolt, duct. Extreme care was immediately taken ti prevent more stones from entering the common duct by clamping off the ampulla of the gall bladder. The cystic duct was then isolated and tied in continuity. The common duct was then opened and thirteen faceted stones of all sizes were removed by irrigation. At the end of the irrigation, no further stones could be palpated and the surgeon and his assistant believed that there were probably none left. Before taking a cholangiogram, it was decided to use the suction technic previously described herein. The
From the Department of Surgery, New York Polyclinic Hospital, New York, New York.
HE METHOD described herein is a very old
T one and has probably
been used by many. In discussing its excellent results with colleagues, however, I was surprised to note that it was used very infrequently. It is therefore being presented in detail as a review, and I am sure it will prove most valuable in the removal of elusive stones in the common duct, particularly those which are in the hepatic ducts. The method consists of attaching strong suction to the proximal cut end of a No. 16 catheter or larger using a medicine dropper as a connecting rod to the suction tubing. The distal end of the catheter is fashioned into a small cup. With the suction blocked, this end is inserted into the common duct and its tributaries. Suction is released suddenly and the stone, if present, is frequently drawn into the cup. (Fig. I.)
FIG. 1. The successful removal from the hepatic ducts.
of unsuspected stones
598
American Journal of Surgery
Common suction end was repeatedly introduced into the left and right hepatic ducts? and to our surprise it produced four additional stones. These unquestionably would never have been secured by any other method. They either were forced up there by our irrigation or were present before the operation [4,5]. After their removal, a cholangiogram was taken on the operating table and revealed no stones. The dye entered the duodenum with great ease. SUMMARY
A simple method for the removal of the elusive common duct stone is presented as a reminder of its effectiveness.
Duct
Stone
599 REFERENCES
1. COLCOCK,B. P. An Additional Aid in Exploration of the Common Bile Duct. Lahey Clin. Bull., 10: 73, 1956. 2. GLESN, F. Common duct exploration for stones. Surg., Gynec. & Obst., 95: 431, 1952. 3. PAYNE, J. R. and FIRME, C. xi. Problem of overlooked common duct stone. -4~. Surgean, 20: 1171, 1954. 4. COLCOCK, B. P. and LIDDLE, H. ‘1;. Common bile duct stones. n7ervEngland J. Med., 258: 264, 1958. 5. SINGLETON,A. O., JR. and COLEMAN, J. L. Residual common duct calculi. Ann. Surg., 143: 619, 1956. ADDITIONAL REFERENCES
NOT CITED IN TEXT
COBO, A., HALL, R. C., and TORRES, E. Intrahepatic calculi. Arch. of Surg., 89: 936, 1964. HUGHES, E. S. R. Recurrent and residual stones in common bile duct. &it. J. Surg., 43: 198, 1956.