Primary Common Bile Duct Stones Research Articles

Review Article: Spectrum of Biliary Infections in the West and in the East

Biliary infections are an important cause of morbidity in the Western world. With regard to epidemiology, etiology, microbiological spectrum, prevalence, location and composition of gallstones, pathogenesis, clinical sign and therapy, there are large differences between the spectrum of biliary infections in the East and in the West (Table 1). In Western countries, gallstones are found in 10 to 40%. In Eastern countries, the incidence of gallstones is only 2 to 6%. Some eighty – five percent of the gallstones in the West are cholesterol stones, in contrast to the East, where 97% are bile pigment stones. The most important difference is characterized by the origin of common bile duct stones. In the West, common bile duct stones generally originate in the gallbladder, in contrast to the East, where primary common bile duct stones are often found – especially in the intrahepatic segments – with no evidence of gallbladder stones. The sex distribution male to female in the West is 1:2, in the East 1:1. In the West, biliary infections occur mainly in an elderly population, 50% being older than 70 years. In the East, biliary infections appear also in younger people, 50% being younger than 40 years. Parasites play an aetiological role in the East, but not in the West. The typical therapy of gallstones in the West is cholecystectomy, and of common bile duct stones endoscopic sphincterotomy. Due to the frequency of intrahepatic stones in Eastern Countries, the therapeutic spectrum there includes even large hepatic resections and biliary enteric anastomoses.

The “Stent through Stent Technique” for Hilar Malignant Stenosis Complicated with Common Bile Duct Calculi

Abstract: We report here on a patient who had a Bismuth type III hilar malignant stenosis and a primary common bile duct calculi which was an added complication. This stenosis was effectively treated by a “stent through stent technique”, that consisted of two metal stents braided together by expanding a wire gap in the mesh of the first stent and inserting the last one through this former dilated wire gap, achieving bilateral biliary drainage. The primary common bile duct stone was treated by percutaneous cholangioscopically‐guided electrohydraulic lithotripsy. This technique might be applied on a large series of patients with hilar malignant stenosis and in the case of the uncommon association with primary common bile duct calculi electrohydraulic lithotripsy using the percutaneous approach should be considered as a good approach.

Primary Choledochoduodenostomy for Benign Obstructive Biliary Tract Disease

Repeated surgical interventions on the biliary ductal system increase morbidity and mortality, particularly in the geriatric patient. In an attempt to prevent these complications, side-to-side choledochoduodenostomy was performed as the primary operative procedure in 54 patients, age 72 +/- 13 years. This was the patients' first surgical intervention for benign obstructive lesions of the biliary tract system. Indications for choledochoduodenostomy were: multiple or irremovable common or hepatic duct stones, doubtfulness of complete clearing of the duct, primary common bile duct stones or mud and sludge, a grossly dilated biliary duct system, and ampullary stenosis. We encountered no operative or hospital mortality among this group of 54 patients. The mean postoperative hospital stay for this aged and relatively sick group of patients was 12.3 +/- 6.2 days. Twenty-three minor postoperative complications occurred in 18 patients, none of them requiring reoperation. The patients were followed for 2-16 years. Thirteen patients (24%) were lost to follow-up. Of the 41 patients available for follow-up, 14 died, none from biliary tract associated causes--mostly from cerebrocardiovascular disease. Twenty-seven patients still alive were found to be free of biliary tract associated abdominal complaints or recurrent cholangitis for a mean period of 7.8 +/- 3.7 years. The data indicate a zero reoperation rate during long-term follow-up, zero mortality rate, and low morbidity in a group of elderly, mostly poor risk patients. This leads us to conclude that a side-to-side choledochoduodenostomy is both the best therapy as well as prophylaxis against common duct stones. This, even in this era of endoscopic papillotomy and biliary lithotripsy.

The incidence and significance of common bile duct dilatation in biliary calculous diseases.

AbstractTo assess the significance of common bile duct dilatation in biliary lithiasis, we studied 3,802 patients who underwent surgery for biliary calculous disease. It has been shown that there is a higher incidence of common bile duct dilatation in patients of advanced age, in those with a long history of symptoms, and in those who have undergone previous biliary surgery. Furthermore, it has been noted that common bile duct dilatation is associated with a high incidence of bile infection of primary common bile duct stones and of pathological changes on the biliary tree histology. These findings support the view that common bile duct dilatation should be considered as an end result of advanced biliary tree disease and it may well predict a high potential for recurrent choledocholithiasis.

Refractory primary common bile duct stone disease

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.

Primary common bile duct stones.

AbstractPrimary or stasis stones in the common duct are a distinct clinical, anatomical, and pathological entity. In the older patient with chills, fever, and jaundice, it is axiomatic that a primary or stasis stone will be found in a common duct that measures 20 mm or more in diameter. Furthermore, about 20% of such patients will not have stones in the gallbladder. The symptom of chills, having not been observed in patients with cancer of the head of the pancreas, is considered a diagnostic aid in the differentiation of jaundice secondary to common duct stones from jaundice due to malignant obstruction. The primary or stasis stone is the most common type of common duct stone. When present, a definitive operation, preferably choledochoduodenostomy, is advised. A simplified classification of biliary tract stones, preferably that of Aschoff, should be established as the universal standard. Also, based on this standard, worldwide prospective clinical studies should be initiated to obtain data for comparative evaluations to determine the true incidence of primary common duct stones.