Distal Common Bile Duct Stone Research Articles

The Clip That Got Away: A Migrated Cholecystectomy Clip as a Nidus for Distal Common Bile Duct Obstruction and Stone Formation

Purpose: 43 year old male presented with a one week history of fatty food intolerance, clay colored stools, and right upper quadrant pain. He underwent cholecystectomy 2 years ago for cholelithiasis and similar pain. A right upper quadrant ultrasound showed no ductal dilation, no intraductal lesion, and confirmed a previous cholecystectomy. Within 6 hours of admission, his bilirubin and alkaline phosphatase were double the normal values and his transaminases were seven times the normal values. A CT scan of the abdomen and pelvis with IV contrast showed no abnormalities from the AP view. Based on his clinical picture, ERCP was performed. The initial endoscopic image showed a clip encased in a stone at the ampulla (A). After wire cannulation past the stone, bile and pus began to flow out of the ampulla. A sphincterotomy was performed and the stone and clip were removed by balloon sweeps (B). Upon further review of the CT, a metal object was seen at the ampulla on sagital images (C)(box). Within 24 hours, the patient was back to his baseline and was discharged home. One similar case of a cholecystectomy clip causing obstruction and cholangitis was published in OVID (1).FigureFigureFigure

Extracción de cálculo coledociano de gran tamaño con esfinterotomía biliar seguida de dilatación de la papila con balón hidrostático

An 83-year-old woman was admitted because of colicky pain in the abdominal right upper quadrant and a cholestatic pattern in liver chemistry. Transcutaneous abdominal ultrasound showed a huge dilation of the extrahepatic bile duct. A distal common bile duct stone was also observed. An endoscopic retrograde cholangio-pancreatography (ERCP) was performed. Vater’s papilla was located in the right rim of a duodenal diverticulum. At cholangiography a common bile duct stone was observed. It was ovoid in shape and had a size of 19 mm in the largest diameter (Fig. 1). An endoscopic biliary sphincterotomy procedure was performed. As Vater’s papilla was in a juxtadiverticular position, sphincterotomy size could not be extended beyond approximately 5 mm. This papillary opening seemed unlikely to allow common bile duct stone extraction. Then a sphincterotomy dilatation was performed. A 15-mm in diameter hydrostatic balloon was employed (Figs. 2 and 3). Afterwards, the common bile duct was swept with an extraction balloon and choledocholithiasis was removed (Fig. 4). The common bile duct stone slipped easily through the dilated papillary opening even though its size was greater than the papillary dilatation.

Laparoscopic Transduodenal Sphincteroplasty

Common bile duct stones are a difficult problem, often leading to conversion to an open operation or repeated endoscopic procedures. Both strategies are associated with added morbidity. A new technique was developed to perform a traditional sphincteroplasty using minimally invasive methods. The procedure was performed on two patients with distal common bile duct stones; each patient had previously undergone at least two unsuccessful preoperative endoscopic retrograde cholangiopancreatography procedures by at least two different experienced endoscopists. In both patients, a laparoscopic transduodenal sphincteroplasty was successfully completed. A transduodenal common bile duct exploration was performed at the time of sphincterotomy, successfully clearing the common bile duct in both cases. There were no untoward postoperative sequelae. Follow-up at one year was satisfactory in both patients. Laparoscopic transduodenal sphincteroplasty can be safely performed in patients with common bile duct stones refractory to endoscopic retrograde cholangiopancreatography. This technique offers a new approach to the management of common bile duct stones, and can spare patients the need for an open operation or subsequent endoscopic procedures.

A patient with abdominal pain and markedly elevated transaminase levels after cholecystectomy

A 33-year-old white female with a history of cholecystectomy presented to the emergency department with intermittent severe abdominal pain radiating from the left upper quadrant to the right upper quadrant, associated with nausea and emesis. Three weeks previously the patient had presented to the emergency department with similar pain in the abdomen. Laboratory investigations had revealed elevated bilirubin, transaminase, and alkaline phosphatase levels. At that time, pain and liver chemistry test results improved and the patient was discharged on hospital day 3. She denied a history of alcohol use, new medications, or the ingestion of other toxins. History and physical examination, liver chemistry tests, viral hepatitis serology tests, autoimmune serology tests, abdominal ultrasound, liver biopsy, and an endoscopic retrograde cholangiopancreatogram. Choledocholithiasis. Endoscopic retrograde cholangiopancreatogram with sphincterotomy, removal of an 8 mm distal common bile duct stone, and pancreatic stent placement.

Giant liver abscess due to almost asymptomatic common bile duct stone

Solitary pyogenic liver abscess is usually caused by a metastatic infection through the portal blood flow or through the hepatic arterial blood flow from extra-abdominal pyogenic foci. Besides, it may be the result of local inflammatory diseases, such as cholecystitis, hydatid cyst, haematomas particularly with retained foreign bodies, etc. Suppurative cholangitis usually causes multiple pyogenic liver abscesses. Solitary pyogenic abscess is rarely caused by cholangitis, but practically always by suppurative cholangitis. Giant pyogenic liver abscess due to asymptomatic or mild cholangitis is a rarity. We present on a 63 year old man who developed a giant solitary pyogenic liver abscess in whom no other possible cause could be found or anticipated except practically almost asymptomatic choledocholithiasis accompanied with mild elevation of bilirubin content, alkaline phosphatase and gamma-GT. The patient was successfully treated operatively. Over 1800 ml. of pus was aspirated from the abscess cavity. Operative cholangiography performed in spite of the absence of gall bladder stones undilated and noninflamed common bile duct stone showed a small nonobstructing distal common bile duct stone. The duct was not dilated, the bile was clear and there were no signs of cholangitis in the inside of the common bile duct. Cholecystectomy and abscess cavity drainage led to uneventful recovery. The patient has been symptom-free for more than 3.5 years.

Intraoperative Choledochoscopic Electrohydraulic Lithotripsy for Difficultly Retrieved Impacted Common Bile Duct Stones

A difficultly retrieved, impacted distal common bile duct stone is sometimes encountered during supraduodenal common bile duct exploration. Transduodenal sphincteroplasty is usually performed when such stones cannot be retrieved by conventional methods, but not without risk. To achieve clearance of such complicated stones and to avoid the potential risks of transduodenal sphincteroplasty. Prospective clinical trial. Medical college-affiliated hospital and tertiary care center. From July 1991 to April 1993, 10 patients met the following inclusion criteria: (1) an impacted distal common bile duct stone found during supraduodenal common bile duct exploration and (2) failure of conventional methods such as stone forceps, a basket, flushing with normal saline solution, or a Fogarty catheter to retrieve stones via the supraduodenal choledochotomy. Another 10 patients with the same problem, treated with transduodenal sphincteroplasty from February 1989 to May 1991, were used as a comparison group. Intraoperative choledochoscopic electrohydraulic lithotripsy was applied with continuous visualization through a choledochoscope. Effectiveness of stone fragmentation and possible complications. Stones were fragmented and successfully removed by a basket and flushing with normal saline solution. Mild oozing was noted in one patient, but soon stopped spontaneously. The mean operative time of the clinical trial group was significantly shorter (P = .004) than that of the comparison group; the mean postoperative stay was 4 days shorter. The complication rate of the clinical trial group (10%) was lower than that of the comparison group (40%). The 10 successfully treated patients of the clinical trial group remain well, with a mean follow-up of 22 months. Intraoperative choledochoscopic electrohydraulic lithotripsy is a safe and effective method for removal of impacted distal common bile duct stones.

Technical problem: Impacted retained distal common duct stone

We report a three-stage technique for use when impacted, retained distal common bile duct stones are encountered. It minimises instrumentation of the ampullary region during any one interventional session, provides drainage of biliary and pancreatic ducts between sessions and, in our opinion, maximises the chances of safely extracting such a stone.

The surgical management of impacted common bile duct stones without sphincter ablation.

Thirty-two consecutive patients with impacted ampullary or distal common bile duct stones were managed prospectively. Preoperative indications for surgery were obstructive jaundice in 13 patients (40.6%), acute cholangitis in 7 patients (21.9%), biliary pancreatitis in 6 patients (18.8%), acute cholecystitis in 5 patients (15.6%), and chronic cholecystitis in 1 patient (3.1%). No patient had a prior cholecystectomy, and all stones were removed retrograde during cholecystectomy and open-duct exploration. There were no deaths, one retained stone in the biliary radicals, two episodes of mild pancreatitis, one superficial wound infection, and one minor bile leak. All patients have done well on follow-up. This study demonstrated that impacted biliary stones can be consistently and successfully extracted by the supraduodenal approach with minimal morbidity and no mortality, without resorting to duodenotomy and sphincter ablation.