Bile Duct Calculi Research Articles

Combined laparoscopic and endoscopic treatment of gallstones and bile duct stones: a prospective study.

In patients with symptomatic gallstones the management of choledocholithiasis has been controversial since the introduction of laparoscopic cholecystectomy. A prospective study was made of 300 consecutive patients with symptomatic gallstones managed by laparoscopic cholecystectomy and preoperative endoscopic retrograde cholangiography (ERC) over 2 years. Fourteen patients were excluded either because urgent surgery was required or because they were unfit for laparoscopic cholecystectomy. ERC was performed on 96 patients (34 per cent) who were at risk of choledocholithiasis. The presence of bile duct calculi was confirmed in 59 patients (21 per cent of the total, 61 per cent of those undergoing ERC); stones were removed endoscopically in 53 cases (90 per cent of attempts). The remaining six patients underwent open cholecystectomy and bile duct exploration. Laparoscopic cholecystectomy was attempted in 280 patients (98 per cent); it was necessary to convert to open operation in only three (1 per cent). There were no deaths, no retained stones and no bile duct injuries, and only three patients (1 per cent) developed a significant postoperative complication. Symptomatic gallstones can be managed by preoperative ERC and laparoscopic cholecystectomy with minimal morbidity and mortality.

Endoscopic sphincterotomy for retained common bile duct stones in patients with T-tube in situ in the early postoperative period.

We report on thirty-nine patients who underwent endoscopic sphincterotomy (ES) and stone extraction for retained common bile duct calculi with a T-tube in situ. Sixteen of the patients had undergone unsuccessful attempts at removal by flushing or dissolution by cholesterol solvents. A total of 76 stones were present: 53 distal to the T-tube and 23 proximal to the T-tube. ES and clearance of the common bile duct was achieved in 37 patients (95 per cent) and complications occurred in three patients (7.7 per cent). This method is an effective and relatively safe method in the early postoperative period allowing rapid treatment during the same admission as for the original operation and early hospital discharge.

Non-operative treatment of retained bile duct calculi in patients with an indwelling T tube.

The results of combined instrumental and chemical treatment of retained bile duct calculi in 18 patients with an indwelling T tube are reported. The instrumental extraction of stones was carried out through the T tube channel using a modified Dormia apparatus. The chemical method involved continuous infusion through the T tube of heparin in saline alternating with sodium cholate. The treatment was successful in 16 of 18 patients with from 1 to 14 residual stones. The instrumental extraction of stones is recommended as the treatment of choice 5--6 weeks after choledochotomy in patients with residual stones and an indwelling T tube. Subsequent chemical treatment is recommended if remnants of stones are left in the bile duct after instrumental treatment.

Kocher's perampullary approach for common bile-duct calculi.

Abstract Supraduodenal choledochotomy for common bileduct stones carries the risk of biliary leakage, a predilection to stricture, and no certainty that all the stones are removed. Stones left behind after the first exploration and new stones formed later require secondary surgery, which is often difficult and has an even greater risk of serious complications. Perampullary exploration, on the other hand, does not carry an increased initial risk of death or of the complications of biliary fistulae and retained stones of which none occurred in this series. Late complications of stricture and secondary unpassable stones similarly did not occur. Neither method is free from the risk of postoperative pancreatitis (1 per cent in this series), but there is no evidence that perampullary exploration carries a greater risk than supraduodenal exploration. Even so, it is considered wise to give propantheline for 72 hours after perampullary exploration to reduce this risk. It has been suggested that a wide, poorly competent, distal common-duct orifice might predispose to ascending cholangitis. No case in this series developed such cholangitis, nor has any case developed stenosis at the sphincteroplasty which might encourage cholangitis. In fact, in the 3 cases that came to post-mortem examination at intervals of 2 and 3 years the sphincteroplasties were still widely patent. Boulter (1961) suggested that sphincterotomy increased the flow of bile in the physiological pressure range and thus might be an additional benefit from the procedure.

The non-absorbable cystic duct ligature.

Abstract A case is reported of a common bile-duct calculus which had formed around a non-absorbable cystic duct ligature used during cholecystectomy 6 years previously. Although there are advantages in the use of the non-absorbable cystic duct ligature, the risk of migration to the common duct and consequent stone formation is probably greater than is recognized.

GI Fellowship Training-The Missing Piece

When I began GI fellowship, there was only one proton pump inhibitor available. Gallstones and bile duct calculi were being dissolved and pulverized. Endoscopic ultrasound was being promoted as a futuristic diagnostic tool, but was still a technique struggling to justify its existence. Campylobacter pyloridis (as Helicobacter pylori was named then) infection was heralded as a breakthrough in understanding the pathophysiology of peptic ulcer disease. Sonde enteroscopy was exploring the final alimentary frontier as it tortured patients suffering from presumed small bowel bleeding. Eager GI fellows like us, our program directors promised, could learn all that we needed to know in just 2 short years.

Die minimal-invasive Sanierung der Choledocholithiasis

Common bile duct stones may present a health hazard for our patients. Nevertheless, since the implementation of laparoscopic cholecystectomy optimal diagnostic and therapeutic algorithm are not yet defined. Symptomatic calculi can be assumed on the basis of pathological laboratory values or diagnosed by means of ultrasound, Intraoperative Cholangiography (IOC) or Magnetic-Resonance-Cholangio-Tomography (MRCT). For therapy of common bile duct stones endoscopic and laparoscopic minimally-invasive strategies are available. As any type of management may show some benefit, it is not yet evident which policy we should prefer. Specialists do not agree on the necessity of therapy in asymptomatic patients with common bile duct calculi at all. This article shows a current state of the opinion and art and tends to highlight trends and future perspectives.

Feasibility of laparoscopic common bile duct exploration in a rural centre

Laparoscopic common bile duct exploration has emerged as a preferred option for the management of choledocholithiasis. The present study sought to review the feasibility of this technique in a rural centre. A comprehensive retrospective review was undertaken of all patients who underwent surgical treatment of biliary calculi in Lismore, NSW (Australia), between January 1996 and December 2002. During the study period, 1567 consecutive patients underwent laparoscopic cholecystectomy, of whom 82 (5.2%) had choledocholithiasis identified at intraoperative cholangiography. A total of 86 laparoscopic common bile duct explorations were undertaken in these patients, 37 (43%) via a transcystic approach, and 49 (57%) via a laparoscopic choledochotomy. All common bile duct calculi were successfully removed in 78 cases, representing an overall duct clearance rate of 90.7%. Complications were noted in seven patients, a morbidity rate of 8.5%. Median operative time for the procedure over the study period was 173 min. Median hospital stay was 6 days for all patients. Laparoscopic common bile duct exploration can be successfully undertaken in a rural setting by general surgeons who have appropriate laparoscopic experience, and should be the procedure of choice for the management of choledocholithiasis in these patients. It should not be restricted to specialized surgical departments in major referral centres.

Magnetic Resonance Cholangiopancreatography in Obstructive Jaundice

To determine the ability of magnetic resonance cholangiopancreatography (MRCP) to diagnose the level and cause of obstruction in patients with obstructive jaundice. The limitations of available imaging modalities have led to the increasing use of MRCP, which is a noninvasive and highly accurate technique in evaluating patients with biliary obstruction. Thirty patients were included in this study. MRCP was done using a fat suppressed, heavily T2 weighted fast spin echo sequence. The MRCP findings were confirmed on surgical exploration or clinical follow-up. MRCP could correctly identify ductal dilatation and the level of obstruction in all cases, except one. All causes of obstruction, except three, were detected. It failed to detect a common bile duct calculus in a minimally dilated ductal system and misdiagnosed a case of focal chronic pancreatitis as carcinoma head pancreas and a small pancreatic head mass as cholangiocarcinoma. It had a sensitivity of 94.44%, specificity of 81.81%, positive predictive value of 89.47%, and negative predictive value of 90% for the detection of malignant causes. The overall diagnostic accuracy for detection of level and cause of obstruction was 96.3% and 89.65%, respectively. The high diagnostic accuracy of MRCP in evaluating patients with obstructive jaundice indicates that it has the potential to become the diagnostic modality of choice in such patients.

Laparoscopic operation for recurring bile duct calculus

目的 探讨腹腔镜结合胆道镜治疗肝内外复发性胆管结石的可行性.方法应用腹腔镜对肝内外胆管复发结石再次手术治疗,行胆总管切开取石,置T管引流术,术中及术后应用胆道镜取石.结果本组15例胆管复发结石病人,13例应用此方法,成功地治疗肝内外胆管复发结石;2例因腹腔粘连较重,中转开腹手术.结论在熟练掌握腹腔镜技术的基础上,应用腹腔镜能完成复发性胆管结石的手术治疗,达到微创的目的。

Percutaneous treatment of biliary stones: sphincteroplasty and occlusion balloon for the clearance of bile duct calculi.

Our study describes the percutaneous expulsion of bile duct calculi into the duodenum by dilating the papilla with a balloon catheter. SUBJECTS AND METHODS. Patients (n = 212; 101 men and 111 women; mean age, 73 years; range, 31-95 years) had their calculi (single, 131; multiple, 81) percutaneously expelled into the duodenum in 73 patients via an indwelling T tube, and in 139 via transhepatic or transcystic duct route. Stone expulsion was facilitated with an occlusion balloon after balloon sphincteroplasty and with prior mechanical fragmentation in only 37 patients. After the expulsion of the calculi into the duodenum, drainage of the main bile duct to the exterior was maintained for 2-8 days. Technical success was initially 90.4%, increasing to 93% at the second attempt. There were 13 failures due to the large size of the calculi in nine patients, excessive tortuosity of the T tube (Kher tube) in one, and breaches of the established protocol in two. Residual lithiasis was resolved in 98.6% of cases, decreasing to 92% in the group of native, or nonresidual, lithiasis. There were 10 major complications (hemobilia) with three cases of poor clinical outcome: hepatic necrosis, multiorgan failure, or death. Percutaneous anterograde evacuation of bile duct stones with dilatation of the papilla using an angioplasty catheter and assisted with an occlusion balloon to expel the calculi is a cost-effective, nontraumatic, and safe procedure that retains the anatomic and functional integrity of the sphincter. It is a viable alternative procedure in the treatment of bile duct lithiasis.

A prospective study of common bile duct calculi in patients undergoing laparoscopic cholecystectomy: natural history of choledocholithiasis revisited.

To define the incidence of problematic common bile duct calculi in patients undergoing laparoscopic cholecystectomy. In patients selected for laparoscopic cholecystectomy, the true incidence of potentially problematic common bile duct calculi and their natural history has not been determined. We evaluated the incidence and early natural history of common bile duct calculi in all patients undergoing laparoscopic cholecystectomy with intraoperative and delayed postoperative cholangiography. Operative cholangiography was attempted in all patients. In those patients in whom a filling defect was noted in the bile duct, the fine bore cholangiogram catheter was left securely clipped in the cystic duct for repeated cholangiography at 48 hours and at approximately 6 weeks postoperatively. Operative cholangiography was attempted in 997 consecutive patients and was accomplished in 962 patients (96%). Forty-six patients (4.6%) had at least one filling defect. Twelve of these had a normal cholangiogram at 48 hours (26% possible false-positive operative cholangiogram) and a further 12 at 6 weeks (26% spontaneous passage of calculi). Spontaneous passage was not determined by either the number or size of calculi or by the diameter of the bile duct. Only 22 patients (2.2% of total population) had persistent common bile duct calculi at 6 weeks after laparoscopic cholecystectomy and retrieved by endoscopic retrograde cholangiopancreatography. Choledocholithiasis occurs in 3.4% of patients undergoing laparoscopic cholecystectomy but more than one third of these pass the calculi spontaneously within 6 weeks of operation and may be spared endoscopic retrograde cholangiopancreatography. Treatment decisions based on assessment by operative cholangiography alone would result in unnecessary interventions in 50% of patients who had either false positive studies or subsequently passed the calculi. These data support a short-term expectant approach in the management of clinically silent choledocholithiasis in patients selected for LC.

Bile duct obstruction due to portal biliopathy in extrahepatic portal hypertension: surgical management.

Varices can develop in and around the bile duct in the presence of portal hypertension, especially when it is caused by extrahepatic portal vein thrombosis. The term 'portal biliopathy' is used to describe changes in the bile duct due to these varices, which may cause bile duct obstruction. This paper reviews experience of the surgical management of patients with symptomatic portal biliopathy. Nine patients with extrahepatic portal vein obstruction with symptomatic portal biliopathy. were reviewed retrospectively. Eight patients presented with jaundice, two had abdominal pain and one had recurrent cholangitis. Endoscopic retrograde cholangiography revealed abnormality of the bile duct wall, with stricture in eight patients and bile duct calculi in two. Portasystemic shunting relieved jaundice in five of seven patients, and in two a second-stage hepaticojejunostomy was required. Symptomatic biliary obstruction in patients with extrahepatic portal hypertension may be relieved by a portasystemic shunt. Rarely biliary bypass may be required and is rendered safer by previous portasystemic shunting to decompress the pericholedochal varices. A direct approach to the biliary tract without a preliminary shunt may be hazardous and is frequently unnecessary.

Strategies for endoscopic and surgical treatment of biliary tract calculi

Common bile duct calculi represent a pathologic entity involving obstructive icterus, cholangitis, hepatic cirrhosis or pancreatitits. Common bile duct calculi mostly have a secondary origin (from gallbladder) in 95% of cases, while primary choledocholithiasis is rare. From surgical aspect, common bile duct calculi can be: 1. Asymptomatic, without manifested symptoms or signs, 2. Mobile, with intermittent biliar obstruction and disobstruction, 3. Fixed, with obstruction and signs of hepato-biliary and/or bilio-pancreatic duct, 4. Transitory, microcalculi which pass through Vater's Papilla by propulsion into duodenum with symptoms. Modern biliary surgery includes diagnosis of common bile duct calculi, and if possible preoperative endoscopic (endoluminal) surgery, which is less invasive for patients. If such approach is not possible, it is necessary to perform stone extraction and cholecystectomy. Common bile duct calculi represent a common disease of the digestive system. Endoscopic diagnostic procedure is very important in management of choledocholithiasis. Endoscopic treatment of common bile duct calculi prior to cholecystectomy is a method of choice and a strategy for associated cholecysto-choledocholithiasis.

Diagnosis of common bile duct calculi with intraductal ultrasonography during endoscopic biliary cannulation.

Choledocholithiasis can be difficult to diagnose, even with direct cholangiography. We examined the role of biliary intraductal ultrasonography in detecting common bile duct stones that had been overlooked during endoscopic retrograde cholangiopancreatography. Eighty consecutive patients who underwent endoscopic retrograde cholangiography for suspected choledocholithiasis with negative results were evaluated with intraductal ultrasonography (20 MHz) for the presence of biliary concrements. The diagnostic criterion for stones was a strong-echo structure with acoustic shadowing. Materials of low amplitude echoes without acoustic shadowing were considered sludge. Intrabile duct scanning was successful in all patients. Of the 80 patients, 20 (25%) had ultrasonic evidence of common bile duct stones. The stones measured 5 mm or less on ultrasound and their presence was confirmed macroscopically during endoscopic (17 patients) or laparoscopic (three patients) bile duct clearance. Another 37 patients (46%) had biliary sludge alone and have been followed up uneventfully. Biliary intraductal ultrasonography may become a useful adjunct to establish the diagnosis of occult bile duct concrements and a guide to appropriate therapeutic selection during endoscopic biliary cannulation.

Clinical Utility and Role of Magnetic Resonance Cholangiography in the Evaluation of Choledocholithiasis Prior to Laparoscopic Cholecystectomy

Purpose: To compare the findings of MR cholangiography with those of ultrasound and biochemistry in patients with suspected choledocholithiasis, and to evaluate the clinical utility and role of MR cholangiography prior to laparoscopic cholecystectomy. Materials and Methods: We retrospectively reviewed the radiologic findings and clinical records of 103 consecutive patients in whom choledocholithiasis was suspected and who underwent both ultrasound and MR cholangiography. For MR imaging, a 1.5T unit was used, and axial T1-FLASH, True FISP, and oblique coronal HASTE and RARE images were obtained. Initial biochemical values (AST, ALT, total bilirubin) were correlated with the findings of MR cholangiography. Results: Choledocholithiasis was present in 36 of 103 patients: overall, there were 34 true-positive, 63 truenegative, four false-positive, and two false-negative results. In the detection of choledocholithiasis, MR cholangiography showed the following characteristics: sensitivity, 94%; specificity, 94%; positive predictive value, 89%; negative predictive value, 96%; accuracy, 95%. Calculi in the common bile duct were detected in 3 of 33 patients (9%) in whom ultrasound showed that the caliber of the common bile duct was normal and whose laboratory findings were normal, and in 12 of 43 (28%) of those whose common bile duct was dilatated or whose laboratory values were abnormal. Calculi were present in the common bile duct of 21 of 27 patients (78%) with abnormal laboratory values and abnormal ultrasound findings. Conclusion: Choledocholithiasis was detected in 25% of patients without clinical suspicion and was not present in 25% of patients with strong clinical suspicion. In patients with this condition, MR cholangiography is noninvasive and accurate, and we suggest that in patients with suspected choledocholithiasis, it should be a routine diagnostic procedure prior to laparoscopic cholecystectomy.

True incidence of common bile duct calculi at laparoscopic cholecystectomy

Choledocholithiasis occurs in 3.5% of patients undergoing laparoscopic cholecystectomy. Of these patients, more than one-third pass the calculi spontaneously and may be spared ERCR This supports a short-term expectant approach in the management of patients with choledocholithiasis.

Robotically assisted minimally invasive biliary surgery in a porcine model.

A robotic surgery system has the potential both to reduce the effects of tremor and fatigue and to enhance dexterity in the performance of complex, fine endosurgical tasks. We report a prospective study of robotically assisted minimally invasive biliary surgery in a porcine model using the Zeus robotic surgical system (Computer Motion, Goleta, Ca, USA). For this study, 50-kg domestic swine were used. Minimally invasive robotically assisted cholecystectomy was performed in 16 animals, either longitudinal or transverse common bile duct incision, T-tube placement, and suture repair of the common bile duct. Retrieval of 12 simulated bile duct calculi was attempted. Eight animals were monitored for 6 weeks postoperatively. Liver function tests and cholangiography were performed 2 and 6 weeks after surgery. The median setup time for the robotic system was 45 min (range, 10-120 min). The median operative time was 40 min (range, 25-60 min) for cholecystectomy and 80 min (range, 40-165 min) for bile duct dissection, exploration, and repair. Of 12 bile duct calculi, 11 were retrieved successfully. Cholangiography demonstrated no leaks, and the anastomotic stenotic index (diameter of the proximal bile duct divided by the diameter of distal bile duct) at 6 weeks was 0.98. The results of the liver function tests remained normal in all animals. One postoperative death unrelated to operative technique occurred. Complications included one minor splenic laceration and two intraoperative gallbladder perforations. Robotically assisted minimally invasive biliary surgery in this animal model is both feasible and safe. The Zeus system provides enhanced dexterity, which facilitates precise laparoscopic suture repair of small bile ducts.

Cholecystocholangiography during laparoscopic cholecystectomy.

The aim of this study was to assess the efficacy and safety of performing cholecystocholangiography through a central venous pressure catheter during laparoscopic cholecystectomy. Laparoscopic cholecystocholangiography was attempted during laparoscopic cholecystectomy for chronic calculous cholecystitis in 40 patients, and considered successful if the biliary anatomy was clearly defined. The procedure was evaluated as successful in 36 patients (90%). It added an average 13.5 min to the operating time. A unsuspected common bile duct stone was identified by cholecystocholangiography in one patient and there were no cholangiogram-related complications. We concluded that laparoscopic cholecystocholangiography is a safe, simple, and quick procedure that can be used as an alternative to cystic duct cholangiography to identify the biliary anatomy and detect any common bile duct calculi prior to laparoscopic dissection.

Evaluation of the predictors of choledocholithiasis: comparative analysis of clinical, biochemical, radiological, radionuclear, and intraoperative parameters.

This prospective study was performed to assess the predictive ability of the various indicators of common bile duct (CBD) calculi, individually or in combination, by analyzing 88 patients with gallstone disease. The patients were classified into two groups according to the presence of 10 predefined criteria. Of 53 patients with one or more risk factors (group 2), 26 harbored CBD calculi; none of 35 patients with no risk factors (group 1) had CBD stones. Jaundice correlated best, with a sensitivity of 69%; and pancreatitis had the lowest sensitivity (12%). Elevated serum bilirubin and alkaline phosphatase levels correlated better than liver enzymes and serum amylase. The sensitivity and negative predictive value of cholescintigraphy scanning for diagnosing CBD calculi were better than those of ultrasonography, the sensitivity being 84% versus 50% and the negative predictive value 95% versus 82%. Endoscopic retrograde cholangiopancreaticography was successful in 94% of the patients, and CBD calculi were diagnosed in 74%. Moreover, peroperative cholangiography was 100% sensitive with no false-positive results. Ultimately, a palpable stone at surgery was the best predictor. When all the criteria were analyzed, it was found that as the number of criteria increased so did the percentage of patients harboring CBD calculi.