Cases Of Common Duct Stones Research Articles

Combination of Preoperative EST, Laparoscopic Cholecystectomy with Choledochotomy, and Postoperative Cholangioscopy in the Treatment of Common Bile Duct Stones

Abstract:A case of common duct stones, successfully managed with a combination of preoperative EST, laparoscopic choledochotomy and postoperative choledochoscopic stone extraction, is reported. A 32‐year‐old man was admitted to our hospital because of jaundice and right hypochon‐dralgia of several‐days' duration. CT, US and ERCP revealed stones in the gallbladder and common bile duct. EST was performed to remove the stones in the common bile duct prior to laparoscopic cholecystectomy. However, the patient developed pancreatitis as a complication of EST, which was successfully managed by conservative therapy. Though some stones remained in the common duct following the first trial of EST, the patient rejected a second round of EST. Laparoscopic cholecystectomy and choledochotomy were performed to remove the gallbladder and the stones remaining in the common bile duct. A T tube was placed in the incised common bile duct for management of possible retained stones. Twenty days after the surgery, successful postoperative cholangioscopy was performed, and the stones remaining in the common duct were removed. Hyperamylasemia and pancreatitis are relatively common complications of EST occurring in about 7% of cases, but only 3% of these patients experience severe pancreatitis, requiring hospitalization. Conservative therapy is always the treatment of choice. In our particular patient, pancreatitis caused by EST was successfully managed by decompression with ENBD and administration of ulinastatin. Residual stones in the CBD were completely removed by laparoscopic common bile duct exploration following EST and postoperative cholangioscopy through the T tube fistula.

Usefulness of diagnostic tests for biliary obstruction

We studied the value of tests commonly used in diagnosing obstructive jaundice in 178 patients operated on for biliary obstruction. Ultrasonography had a diagnostic accuracy of 87 percent for gallbladder stones, 82 percent for dilated ducts, and 80 percent for pancreatic masses. Computed tomography was 93 percent accurate in diagnosing dilated ducts, and 93 percent accurate in diagnosing a pancreatic mass. Intravenous cholangiography gave useful information in only 4 of 21 patients. Among 45 patients, endoscopic retrograde cholangiopancreatography was technically successful in 91 percent and gave accurate diagnostic information in 86 percent and partially diagnostic information in 7 percent; it detected all cases of common duct stones and had a 91 percent sensitivity for detecting pancreatic cancer. Among 75 patients, transhepatic cholangiography was technically successful in 95 percent and provided accurate diagnostic information in 90 percent and partially diagnostic information in 3 percent; it detected all cases of common duct stones and 95 percent of cases of benign strictures. With persistent jaundice, ultrasonography should be the first test because it is less costly than computed tomography and provides similar information. If more information is needed, transhepatic cholangiography and endoscopic retrograde cholangiopancreatography are equally accurate; transhepatic cholangiography more often opacifies the proximal biliary tree and endoscopic retrograde cholangiopancreatography provides direct access to the ampulla of Vater and the pancreatic duct.

Intravenous cholecystangiography.

The recent discovery of a chemical compound, Cholografin, has made it possible to demonstrate the bile ducts roentgenographically even though the gallbladder is absent or abnormal. The greatest advantage of this new intravenous method is in studying the biliary tree of the patient who has had a cholecystectomy. It has also proved valuable in cases of gallbladder disease in which the ordinary Graham test has been unsuccessful. This paper, based upon the first 100 cases selected for examination with Cholografin in a hospital and private radiological office in one community, indicates the usefulness, advantages, and limitations of the new chemical. Selection of Patients Originally the limited supply of Cholografin2 restricted its use to cholecystectomized patients, to those in whom nausea or vomiting precluded the employment of an oral medium, and to those in whom diagnosis by the routine oral method was equivocal. Later, as the material became more available, its use was extended to certain cases at the special request of the surgeon or internist. Forty of the group examined had undergone cholecystectomy and in 60 the gallbladder was present. Technic A dose of 20 c.c. of the 20 per cent solution injected into the cubital vein was found sufficient for routine cholecystangiography. In obese patients and in cholecystectomized patients, however, twice that amount was employed. The manufacturer's instructions were followed closely in preparing the patient, testing for sensitivity, rate of injection, and timing the radiographic exposures (1, 5, 7). Special views, such as the vertical, lateral recumbent, and oblique were utilized as indicated. The most rewarding results of an examination occurred when each radiograph was viewed as soon as possible after its development, in order that the technic could be adapted to the individual case. The examination was not carried out when jaundice was present but was delayed until the icterus had nearly or completely subsided. European investigators had reported (4, 7, 8, 11) that in the presence of liver damage Cholografin was excreted mainly in the urine. Results of Examinations The findings in the 40 cholecystectomized patients were as follows: The symptoms in this group varied from mild indigestion to agonizing attacks of biliary colic. The interval between the performance of cholecystectomy and examination ranged from less than a year (in 5 patients) to twenty-five years. In 37 cases Cholografin outlined the biliary tree; in 26 of these the ducts were normal and in 11 some abnormality was found. The 4 cases of common duct stones were confirmed surgically (Fig. 6). Quite impressive were the cystic duct remnants, ranging from 3 to 5 cm. in length (Fig. 5); of even more interest was the sac formation at the end of the cystic duct (Fig. 3). A serious error of interpretation nearly occurred in one patient (Fig. 4), in whom reflux of Cholografin into the duodenal bulb simulated a gallbladder remnant.

Survey of common duct stones in clinical and necropsy cases

1. 1. A statistical review is presented of fifty-nine cases of clinical common duct stones and thirty-three cases of common duct stones found at necropsy with and without symptoms. 2. 2. A resumé of the need and the indications for common duct exploration is listed. 3. 3. A follow-up review of the clinical material is discussed, showing the need for early operative interference and the urgency of common duct exploration in a large percentage of cholecystectomies.