The hazard of retained common duct stones

The

Hazard

of Retained Stones*

ALBERT BEHREND, YKD.AND LESTER G. STEPPACHER, Philadelphia,

Diplomates,

American

Duct Board qf Swgcc~,,

Pennsylvania

s

may be retained in the common bile duct as the resuIt of failure to open the duct at the time of cholecystectomy, or the duct having been opened and searched, one or more stones may be inadvertently allowed to remain. In addition, a smaI1 number of patients seem to have the unhappy abiIity to form stones in the intrahepatic ductal system. In this article we wiI1 attempt to show how serious retained stones foIlowing choIedochostomy can be. The various methods of deaIing with retained stones wiI1 also be considered.

ing cases from one to twenty-three stones were removed from the common duct. The common duct was explored for reasons other than jaundice in ten cases. In eight of these, stones were found, while in two no stones were found but “muddy bile” was present. In the presence of preoperative jaundice one should be extremeIy hesitant to say that stones are not present in the common biIe duct on the basis of exploratory probing alone. The finding of “mud” or solid particles in the bile of the common duct suggests that larger stones are also present. Probes, scoops, forceps and irrigation by saline solution should a11 be used in the search for stones. OccasionaIIy, when the duct is suf%cientIy dilated, the fifth finger may be used as a probe. Palpation of the duct between the thumb and the index finger should always be done, but stones are extremely diffkult to fee1 in this manner when they are Iodged in that portion of the duct which lies behind the head of the pancreas. Because of this, transduodena1 VisuaIization of the papilla of Vater has been done with increasing frequency.

TONES

SELECTION OF PATIENTS A review of the patients operated upon by the severa surgeons and the resident staff at the Jewish Hospital (now the Northern Division of the Albert E‘instein Medical Center) from the years 1936-1950 in which the common bile duct was explored for stones was made. In severa cases the diagnosis of common duct obstruction due to caIcuIi was made without definite confirmatory evidence and these have been eIiminated from this study. There were twenty-five cases in which suff~cient evidence of retained stones was obtained by postoperative cholangiography to form the basis for this report.

DIAGNOSIS OF RETAINED STONES The diagnosis of retained stones is usually made by injecting thirty-five per cent diodrast the T-tube about seven days through after choledochostomy. Recently, operative cholangiography has been used routinely on our service. The resuIts obtained with this method are promising and wiI1 form the basis of another report. However, none of the cases herein reported had cholangiograms done on the operating table. It is important to note that whether the choIangiogram is performed on the operating table or after operation, the method is not fooI-proof. FaIse positive reports are occasionaIIy caused by air bubbIes introduced with the diodrast. Less frequentIy, false negative reports have been obtained by operative

JAUNDICE Jaundice was present as evidence of common duct obstruction in fifteen (60 per cent) of the twenty-five cases at the time of the initia1 common duct exploration and absent in ten (40 per cent). In the fifteen cases with jaundice or a history of jaundice, no stones were found in six at the time of initial exploration of the common duct. In an additiona three of these fifteen cases was noted “Pus,” L‘muddy biIe” or “mud” but no stones were removed. In the six remain* From the Northern

M.D.,

Common

Division, AIbert Einstein Medical Center,

520

PhiIadeIphia, Pa.

Retained Common Duct Stones chiIIs and fever for two years lead to a third operation and remova of a Iarge stone lodged in the ampuIIa of Vater. On the basis of these tindings alone the advisabiIity of T-tube or catheter drainage of the open common bile duct would appear to be justified. The postoperative studies avaiIabIe with such a tube in pIace are ample reward for the time spent in its insertion.

ChoIangiography, with stones demonstrated subsequentIy by postoperative choIangiograms. OccasionaIIy the differentia1 diagnosis between air bubbIes and retained stones is difficuIt. Repetition of the choIangiograms is here indicated. The occurrence of coIicky upper abdominal pain, chiIIs and fever or jaundice with the T-tube cIamped is strong evidence that stones remain. The demonstration of caIcium bilirubinate or choIestero1 crystaIs in the bile is also highIy suggestive of stones. Postmortem examinations and choIangiographic studies have estabIished without doubt that the surgeon is not aIways at fauIt when stones re-appear in the common duct after choIedochostomy or choIedochoIithotomy. Stones have been found even in periphera1 biIiary radicIes at autopsy. By choIangiography we have demonstrated the presence of stones in hepatic ducts too smaI1 to reach with probes and scoops. Such stones may, at any time, journey downstream to Iodge in the common duct and perhaps cause recurrent obstruction. Our experience with the choIeIithophone has not been Iarge but it does not seem to suppIy the answer to the question of how to detect the stone Iying in the far reaches of the hepatic ducts or the stone embedded in the waI1 of the common bile duct. PossibIy operative choIangiography and the cholelithophone shouId be used concurrently to Iower the number of cases of retained stones to an irreducibIe few. OPEKATION

PRIOR

OF

RETAINED

TO

TREATMENT

T-tube

OF

RETAINED

Irrigation.

COMMON

DUCT

STONES

This method was practiced in twenty cases. The soIutions used were saIine, procaine hydrochIoride (2 per cent), and 70 per cent aJcoho1, ether and mineral oil. Most commonIy a mixture of equa1 parts of aIcoho1 and ether was used after prehminary instiIIation of procaine. Irrigation was usually performed daiIy for seven days and the effect checked by further diodrast roentgenograms. Our most serious objection to this method is that despite preliminary procaine hydrochIoride instiIIation, the patient experiences severe pain, presumabIy due to the sudden voIatilization of the ether at body temperature. Patients ma? aIso fee1 “ Jight-headed ” and “ dizzv ” during and for some time after the irrigation. %lost of the pain and discomfort of the irrigations can be avoided by allowing 2 ounces of 2 per cent procaine to drip into the T-tube at a rate of 30 or 40 drops per minute foIJowed by 2 ounces of a mixture of equa1 parts of 70 per cent aIcoho1 and ether. Because the method is not productive of the severe pain of rapid irrigation it can be repeated two or more times daily. We have had the opportunity to use this technic in only two cases, with disappearance of the stones within seven days in both. Its use is suggested as an alternative to the more cornmanly used syringe method of irrigation. T-tube irrigation was successful in six of twenty cases. Either the stones were dissoived or became suffrcientIy fragmented to pass spontaneously as evidenced by their disappearance on subsequent x-ray examination. Two cases unsuccessfuIIy irrigated responded to medical “ fIushes,” one by the Best regimen and one by the administration of belladonna and ohve oil by mouth. Re-operation. Re-expIoration of the common duct was performed in fourteen cases. In a11 but four of these, T-tube irrigation had been used without success. Stones were removed in ten cases but two of these patients

DISCOVERY

STONES

Al1 the patients (twenty-five) had choIecystectomy either in conjunction with choIedochostorny or at some time prior to duct exploration. Three patients had choIecystostom?; and subsequent removal of the gaIIbladder and choledochostomy, whiIe in one patient the gaJIbIadder had been partiaIIy removed and the stump was excised at the time of subsequent choIedochostomy. In four cases choledochostomy aJone was performed at a later date because of symptoms suggesting recurrent or residua1 stones, the gaIIbIadder having been previously removed. In every case biliary tract stones were discovered in the early postoperative period by ChoIangiography, except in one case where sphincterotomy was done several years after choIecystectomy because no stones couId be found by x-ray or operation. The persistence of intermittent 521

Retained Common Duct Stones died foIIowing operation. One death was in a patient eighty-one, who died ten days postoperativeIy of hypertensive cardiovascular disease. The other, a man of sixty-one, died one month postoperativeIy of myocardia1 failure. Autopsy reveaIed biIiary cirrhosis but no residual common duct stones. In 4 cases the stones could not be found at re-operation. In one of these a choIedochojejunostomy was done and the patient has since been asymptomatic. In another case a report of stones by cholangiogram was felt to be erroneous because of faiIure to confirm the findings at re-operation. A third patient, in whom no stones were found, died of cholemia foIlowing an attempted common duct reconstruction at another hospital. A fourth patient was re-expIored three weeks after primary choIedochostomy. No stone was found but the patient has been we11 ever since. An additiona death occurred in a woman, aged fifty-eight, three years after primary choIecystectomy and choIedochostomy. Stones were discovered in the hepatic duct by choIangiography prior to discharge. Re-operation was two years never done. She was re-admitted of choIemia and conIater with symptoms The Iatter condition gestive heart faiIure. impossibIe and death rendered re-operation occurred a year Iater. SUMMARY

AND

Twenty-five cases of choIedochostomy have severa surgica1 services over a period of fifteen

that additiona cases occurred during this period, but onIy patients with rather concIusive evidence of retained stones were studied. In patients with jaundice, or a history of recent jaundice, the search for stones must be painstaking and every method at the surgeon’s command must be used in the search. It is extremeIy diffIcuIt after removing fifteen stones from the common duct to be certain that a sixteenth stone does not remain. From 1936 to 1950 the presence of residual stones was usuaIIy discIosed by choIangiograms made about seven days after choledochostomy. This is something akin to Iocking the stabIe door after the horse has run away. Recent studies indicate that operative choIangiograms may Iead to the detection of retained stones at the optimum time for patient and surgeon, that is, at the first operation. Irrigation of the common biIe duct by saline solution or ether was successful in six of twenty cases in which it was used. A drip modification of the origina Pribram method which was successful in two cases is described. In two additional cases the medica flush method was successfu1. Re-exploration of the common duct was deemed necessary in fourteen cases and three deaths occurred in this group (21 per cent mortaIity). An additional patient died, without operation, of choIemia and congestive heart faiIure. ResiduaI or recurrent stones in the biIiary track constitute a grave surgical hazard. Every avaiIabIe method shouId be used at the time of the origina choIedochostomy to prevent the necessity of re-operation, which carries a high operative risk.

CONCLUSIONS

residual stone after been coIIected from of a general hospita1 years. It is assumed

522