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Technic of extraction of hepatic duct calculi with modified Fogarty catheter and report of a case
MODERN
OPERATIVE
Technic
TECHNIC’S
of Extraction
Calculi with Modified
of Hepatic
Duct
Fogarty Catheter
and Report of a Case IRWIN R. BERMAN, M.D. AND ROBERT B. PFEFFER, M.D., Neze, York, New York
From the Department of Surgery, New York University Medical Center, New York, New York 10016.
insertion into the branches of the hepatic duct. After thorough exploration with Blake forceps, scoops, probes, irrigators, and distal dilators, the catheter (5 or 6 French) is passed in the jaws of the Blake forceps through the choledochotomy up to the bifurcation of the common hepatic duct. The catheter is then advanced into each hepatic duct. Position of the catheter may be confirmed by roentgenogram or palpation of the catheter at the hilus of the liver. If uncertainty as to position exists, two catheters may be passed and their bifurcation palpated at the hilus of the liver. Frequently, after the first catheter is passed and left in place, the second catheter will, upon insertion, be guided automatically to the opposite duct. An attempt is made to detect stones in the ducts by palpation of the duct against the firm intraductal catheter at the hilus of the liver. Each balloon is inflated and withdrawn slowly, care being taken to avoid overdistention of the balloon. Figure 2 shows the biliary catheter and a conventional less opaque vascular catheter in the right and left hepatic ducts, respectively. Once the extraction of all detectable stones has been achieved, irrigation is again performed and the distal duct explored in the conventional manner. A T tube is inserted and a T tube cholangiogram obtained. If small residual calculi high in the hepatic duct remain, a repeated attempt at extraction may be made. It is un-
HE Fogarty balloon-tipped catheter has been
T successfully
employed for several years in extraction of thrombus and embolic material from the great vessels. Its use in selected cases of hepatic duct calculi at New York University Hospital and a later report of its employment in the common duct [1] have prompted this report. The technic and advantages of using a special modification of the Fogarty catheter in the biliary tract are described. Success with extraction of common duct calculi usually varies directly with the skill and experience of the operating surgeon. Palpation, supplemented by the use of conventional forceps, scoops, probes, dilators, irrigators, and operative T tube cholangiography, rarely results in the retention of common duct stones. On the other hand, consistent detection and removal of hepatic duct calculi, especially if they are located high in the hepatic ducts, remain a problem. It is in this area that the use of the balloon-tipped catheter has been most advantageous. The biliary balloon catheter is more opaque and shorter, and its balloon more sturdy than that of the conventional vascular catheter. (Fig. 1.) Marking is provided for the estimation of intraductal distance. Its metal stylet may be employed to shape the tip of the catheter for
* Currently, Captain in the U.S. Arnly and Research Associate, Division of Surgery, Walter Reed Hospital, Washington, D.C. l-01. 114. December
1967
969
man and Pfeffer
970
FIG. 1. Photograph of Fogarty balloon-tipped biliary and arterial catheters. Xote the blunt rubber tip on the biliary catheter.
likely that attempts at extraction beyond this point will be successful. In this rare event, supplementary transduodenal sphincterotomy is frequently employed. This is performed with the realization that subsequent reoperation may be required for removal of remaining stones as they pass down into the common duct. CASE REPORT
(M. A.), a forty-nine year old woman, was admitted to New York University Hospital on March 28, 1967, three years after cholecystectomy, because of episodic epigastric pain radiating to the back and shoulders, dark urine, and acholic stools. There was no history of jaundice. Abdominal examination was unremarkable save for a healed subcostal cholecystectomy scar. Chemical tests of liver function gave normal results except for an alkaline phosphotase of 21.3 Somogyi units and a serum glutamic oxalacetic transaminase of 140 units. Intravenous cholangiograms revealed dilatation of The patient
FIG. 2. Operative roentgenogram biliary catheter in the rigF’ ~_-_rfopaque vascular catheter cc. of 50 per cent Hypaque”
showing opaque ~.._r _-~ *I__ I__..
msrmea mw eacn aauoon,.
the common duct to 18 mm. with apparent distal obstruction, Gastrointestinal series showed duodenal diverticula. The tentative diagnosis of the referring physician was stricture of the common bile duct. At operation on March 30, the old right subcostal wound was re-entered and sharp dissection carried down the under surface of the liver to the porta hepatis. The common duct measured up to 20 mm. in diameter. The cystic duct stump measured 5 mm. in length. A Kocher maneuver was performed to allow palpation of the retropancreatic common duct. No definite stones were palpable within the duct although there was a suggestion of ampullary calculus. Stay sutures of No. 4-O silk were placed medially and laterally in the wall of the common duct and the duct was opened. There was within the duct a considerable amount of soft, friable yellow material which was extracted in addition to a 1 cm. ampullary stone which was milked retrograde into the choledochotomy. Exploration of the common duct, common hepatic, and both hepatic ducts with forceps, scoops, and probes yielded abundant soft yellow stones, When all apparent stones had been removed and after repeated irrigations and catheter suction failed to bring forth further calculi, the Fogarty balloon catheter was passed into each hepatic duct. Withdrawal of the catheter allowed retrieval of an otherwise undetectable 6 mm. residual stone in the right hepatic duct. Repeated irrigation and distal dilatation with Bakes’ dilators were followed by suture of the common duct over a No. 10 rubber T tube, insertion of Penrose drains into Morrison’s pouch, and closure of the abdomen. Operative cholangiography demonstrated no residual calculi. T tube cholangiography performed eight days postoperatively revealed no residual calculi. Dye flowed freely into the duodenum. The patient was discharged on the tenth postoperative day after an uneventful course. SUMMARY
The biliary modification of the Fogarty balloon catheter has been employed successfully American
Journal of Surpcry
Extraction
of Calculi
in the extraction of otherwise undetectable hepatic duct stones. The technic of extraction is described in detail. Replacement of the soft rubber tip by an equally small metal tip would enhance its benefit in detection of these calculi. In this manner, the catheter could be employed as a probe as well as an instrument tion.
I’d. 114. December
1967
for extrac-
from Hepatic
Duct
971
Acknowledgment: We would like to thank the Edwards Laboratories, Inc., Santa Ana, California. for supplying the catheters. REFERENCE
1. KNIGHT,C. D. Use of balloon-tipped catheter in exploration of the common duct. Am. J. Surg., 113: 717, 1967.
OPERATIVE
Technic
TECHNIC’S
of Extraction
Calculi with Modified
of Hepatic
Duct
Fogarty Catheter
and Report of a Case IRWIN R. BERMAN, M.D. AND ROBERT B. PFEFFER, M.D., Neze, York, New York
From the Department of Surgery, New York University Medical Center, New York, New York 10016.
insertion into the branches of the hepatic duct. After thorough exploration with Blake forceps, scoops, probes, irrigators, and distal dilators, the catheter (5 or 6 French) is passed in the jaws of the Blake forceps through the choledochotomy up to the bifurcation of the common hepatic duct. The catheter is then advanced into each hepatic duct. Position of the catheter may be confirmed by roentgenogram or palpation of the catheter at the hilus of the liver. If uncertainty as to position exists, two catheters may be passed and their bifurcation palpated at the hilus of the liver. Frequently, after the first catheter is passed and left in place, the second catheter will, upon insertion, be guided automatically to the opposite duct. An attempt is made to detect stones in the ducts by palpation of the duct against the firm intraductal catheter at the hilus of the liver. Each balloon is inflated and withdrawn slowly, care being taken to avoid overdistention of the balloon. Figure 2 shows the biliary catheter and a conventional less opaque vascular catheter in the right and left hepatic ducts, respectively. Once the extraction of all detectable stones has been achieved, irrigation is again performed and the distal duct explored in the conventional manner. A T tube is inserted and a T tube cholangiogram obtained. If small residual calculi high in the hepatic duct remain, a repeated attempt at extraction may be made. It is un-
HE Fogarty balloon-tipped catheter has been
T successfully
employed for several years in extraction of thrombus and embolic material from the great vessels. Its use in selected cases of hepatic duct calculi at New York University Hospital and a later report of its employment in the common duct [1] have prompted this report. The technic and advantages of using a special modification of the Fogarty catheter in the biliary tract are described. Success with extraction of common duct calculi usually varies directly with the skill and experience of the operating surgeon. Palpation, supplemented by the use of conventional forceps, scoops, probes, dilators, irrigators, and operative T tube cholangiography, rarely results in the retention of common duct stones. On the other hand, consistent detection and removal of hepatic duct calculi, especially if they are located high in the hepatic ducts, remain a problem. It is in this area that the use of the balloon-tipped catheter has been most advantageous. The biliary balloon catheter is more opaque and shorter, and its balloon more sturdy than that of the conventional vascular catheter. (Fig. 1.) Marking is provided for the estimation of intraductal distance. Its metal stylet may be employed to shape the tip of the catheter for
* Currently, Captain in the U.S. Arnly and Research Associate, Division of Surgery, Walter Reed Hospital, Washington, D.C. l-01. 114. December
1967
969
man and Pfeffer
970
FIG. 1. Photograph of Fogarty balloon-tipped biliary and arterial catheters. Xote the blunt rubber tip on the biliary catheter.
likely that attempts at extraction beyond this point will be successful. In this rare event, supplementary transduodenal sphincterotomy is frequently employed. This is performed with the realization that subsequent reoperation may be required for removal of remaining stones as they pass down into the common duct. CASE REPORT
(M. A.), a forty-nine year old woman, was admitted to New York University Hospital on March 28, 1967, three years after cholecystectomy, because of episodic epigastric pain radiating to the back and shoulders, dark urine, and acholic stools. There was no history of jaundice. Abdominal examination was unremarkable save for a healed subcostal cholecystectomy scar. Chemical tests of liver function gave normal results except for an alkaline phosphotase of 21.3 Somogyi units and a serum glutamic oxalacetic transaminase of 140 units. Intravenous cholangiograms revealed dilatation of The patient
FIG. 2. Operative roentgenogram biliary catheter in the rigF’ ~_-_rfopaque vascular catheter cc. of 50 per cent Hypaque”
showing opaque ~.._r _-~ *I__ I__..
msrmea mw eacn aauoon,.
the common duct to 18 mm. with apparent distal obstruction, Gastrointestinal series showed duodenal diverticula. The tentative diagnosis of the referring physician was stricture of the common bile duct. At operation on March 30, the old right subcostal wound was re-entered and sharp dissection carried down the under surface of the liver to the porta hepatis. The common duct measured up to 20 mm. in diameter. The cystic duct stump measured 5 mm. in length. A Kocher maneuver was performed to allow palpation of the retropancreatic common duct. No definite stones were palpable within the duct although there was a suggestion of ampullary calculus. Stay sutures of No. 4-O silk were placed medially and laterally in the wall of the common duct and the duct was opened. There was within the duct a considerable amount of soft, friable yellow material which was extracted in addition to a 1 cm. ampullary stone which was milked retrograde into the choledochotomy. Exploration of the common duct, common hepatic, and both hepatic ducts with forceps, scoops, and probes yielded abundant soft yellow stones, When all apparent stones had been removed and after repeated irrigations and catheter suction failed to bring forth further calculi, the Fogarty balloon catheter was passed into each hepatic duct. Withdrawal of the catheter allowed retrieval of an otherwise undetectable 6 mm. residual stone in the right hepatic duct. Repeated irrigation and distal dilatation with Bakes’ dilators were followed by suture of the common duct over a No. 10 rubber T tube, insertion of Penrose drains into Morrison’s pouch, and closure of the abdomen. Operative cholangiography demonstrated no residual calculi. T tube cholangiography performed eight days postoperatively revealed no residual calculi. Dye flowed freely into the duodenum. The patient was discharged on the tenth postoperative day after an uneventful course. SUMMARY
The biliary modification of the Fogarty balloon catheter has been employed successfully American
Journal of Surpcry
Extraction
of Calculi
in the extraction of otherwise undetectable hepatic duct stones. The technic of extraction is described in detail. Replacement of the soft rubber tip by an equally small metal tip would enhance its benefit in detection of these calculi. In this manner, the catheter could be employed as a probe as well as an instrument tion.
I’d. 114. December
1967
for extrac-
from Hepatic
Duct
971
Acknowledgment: We would like to thank the Edwards Laboratories, Inc., Santa Ana, California. for supplying the catheters. REFERENCE
1. KNIGHT,C. D. Use of balloon-tipped catheter in exploration of the common duct. Am. J. Surg., 113: 717, 1967.