Refractory primary common bile duct stone disease

Abstract

Thirty-seven cases are reported of primary common bile duct stones considered typical of primary stone disease with an asymptomatic period of at least 2 years after cholecystectomy and stones of a soft brown, easily crushable characteristic. Two other groups with a total of 57 cases closely related to those in the first group are reported, for a total of 94 cases. These three groups have similar patient ages, large common bile ducts averaging 19 mm in diameter, ampullas easily open to a no. 6 Bakes dilator and a high incidence of recurrent or overlooked stones despite the use of operative cholangiography in at least half of the procedures. The use of a duct anastomosis in ducts over 11 mm in diameter is mandatory for a satisfactory result. In smaller sized ducts a generous sphincterotomy or sphincteroplasty must be carried out in addition to choledocholithotomy. The exact indication for endoscopic papillotomy in the treatment of this condition has not been settled. Other conditions associated with primary duct stones include traumatic and nontraumatic strictures, sclerosing cholangitis, oriental cholangiolitis, congenital cystic disease, Caroli's disease and congenital hepatic fibrosis. More information is needed to explain the soft stone syndrome, such as data on the bacteriologic and chemical characteristics of the bile and on the physiologic features of common bile duct emptying.