Current management of choledocholithiasis

Choledocholithiasis may be managed by surgical extraction of stones or endoscopic papillotomy with extraction of stones. To evaluate these methods of management, the charts of all patients with choledocholithiasis admitted to Crawford Long Hospital of Emory University between April 1, 1983, and April 30, 1988, were reviewed. One hundred patients were identified; 42 were treated by common bile duct exploration (CBDE) and 58 had endoscopic papillotomy with extraction of stones (EP) as their initial treatment. The two groups were similar in regards to age, but the CBDE group had more comorbid conditions (average 2.5/patient in CBDE vs 1.8/patient in EP) and a higher incidence of acute cholecystitis and/or cholangitis (74% of CBDE patients; 24% of EP patients). Successful extraction of all stones occurred in 79 per cent of CBDE patients and 90 per cent of EP patients. Of those patients with retained stones following CBDE, all were later extracted by EP. Of patients having EP as their initial procedure, 24 per cent required repeat endoscopic procedures for extraction of residual stones and only six patients (10.4%) required CBDE for retained stones. Morbidity was lower (10% vs 23%) and hospital stay shorter (3.6 days vs 10.4 days) in the EP than CBDE patients; thus, the two groups are not completely comparable. Mortality was similar in the two groups (1.7% EP, 2.3% CBDE).     

Reoperative surgery in cholelithiasis

From 1965 to 1980, reoperations for residual or recurrent stones were performed on 78 out of 962 Japanese patients with cholelithiasis. The majority of patients who required reoperation had intrahepatic stones. Most of the causes of reoperation were residual stones due to incomplete removal or the non-detection of intrahepatic stones at the previous surgery. Very careful examination of the intrahepatic biliary trees should be done in patients with biliary tract diseases, because in many, the first operation was done during their youth. To remove the intrahepatic calculi completely, hepatic lobectomy should be considered as a final procedure. The causes of reoperation of common duct stones were residual in 60 per cent and recurrent in 40 per cent. Definitive surgery should be done at the first or at least the second operation to avoid irreversible hepatic disorders which have untoward effects on the prognosis. It is important not only to remove the stones but also to relieve the bile stasis in the biliary tract.     

Endoscopic retrograde cholangiopancreatography in a general surgery practice

Endoscopic retrograde cholangiopancreatography (ERCP) is performed for the diagnosis and therapy of benign and malignant biliary and pancreatic disease. There are few reports in the literature regarding the incorporation of this procedure into a general surgery practice. One hundred seven consecutive ERCPs performed by the same surgeon over a two-year period were reviewed. The most frequent indications for ERCP were jaundice, suspected common bile duct stones, and a history of pancreatitis. Successful cannulation of the ampulla of Vater was achieved in 97 per cent of the cases with the desired duct being adequately visualized in 90 per cent of the cases. Sphincterotomy was performed in 42 per cent of the procedures and common bile duct stones were removed with a balloon or basket catheter. The overall complication rate was seven per cent with no mortality. ERCP accounted for 20 per cent of all endoscopies and 12 per cent of all procedures performed by the surgeon. Twelve per cent of these patients were subsequently operated upon by the surgeon while another 16 per cent requiring surgery were returned to the referring physician. This study supports the feasibility of the incorporation of ERCP into a general surgery practice.     

Complications of biliary surgery

Procedures on the gallbladder and extrahepatic biliary tract were the most frequently performed operations in a series of 1500 consecutive abdominal operations done in community hospitals. The operative mortality rate for elective cholecystectomy was 0.3 per cent. The complication rate was 21.4 per cent for cholecystectomy. Patients requiring emergency cholecystectomy had significantly more urinary tract and intra-abdominal problems than those patients who underwent surgery electively. Operative cholangiography was performed during 20.3 per cent of the elective cholecystectomies. There were no biliary tract complications among the cholecystectomy patients who had cholangiography. When this study was not performed, 1.5 per cent of the patients had postoperative bile duct problems. Older surgeons (greater than 60 years of age) and high volume surgeons (greater than 300 cases/year) were significantly less likely to employ cholangiography. The mortality rate for elective common duct exploration was 4.4 per cent, with a complication rate of 60 per cent. There was a 13.3 per cent incidence of retained stones after choledochotomy, though this problem was readily managed by percutaneous extraction through the T-tube tract. Complex biliary tract procedures were performed electively without mortality, though the complication rate for these procedures was 35.3 per cent. Two-thirds of the patients undergoing complex biliary tract operations on an emergency basis died. Board certified general surgeons had the same mortality and complication rates for cholecystectomy as well as common bile duct exploration. Noncertified surgeons had significantly more intraabdominal complications after complex biliary tract procedures compared to their board certified colleagues.     

Endoscopic sphincterotomy for bile duct stones in patients with intact gallbladders

Endoscopic sphincterotomy was performed in 121 patients (age ranged 34-92 years; median 80 years) with intact gallbladders and bile duct stones. Clearance of the duct by basket or balloon extraction was attempted in 97 patients (80 per cent) and achieved in 93 of these patients (96 per cent). In 24 patients the duct was left to empty spontaneously and this occurred in 22 patients. Immediate complications due to endoscopic sphincterotomy occurred in five patients (two haemorrhage, two perforation, one haemorrhage and perforation). Of the 101 patients reviewed 12-72 months (median 24 months) after endoscopic sphincterotomy, 76 (75 per cent) have remained asymptomatic throughout the follow-up period. Eighteen patients (18 per cent) required cholecystectomy for recurrent gallbladder symptoms 1-24 months after endoscopic sphincterotomy. One of the asymptomatic patients underwent cholecystectomy on the advice of his consultant. A further seven had recurrent biliary colic or cholangitis necessitating enlargement of the sphincterotomy and further stone retrieval in three of these patients. Endoscopic sphincterotomy is an effective treatment for bile duct stones in high risk patients, but subsequent cholecystectomy is required in a significant number of patients owing to continuing gallbladder symptoms.     

Biliary enteric bypass for benign and malignant disease

Between the years of 1970 and 1984, a total of 96 patients underwent biliary enteric bypass to alleviate distal common bile duct obstruction from benign and all malignant disease. Cholecystoenterostomy (CCE) was performed in 13 patients (chronic pancreatitis 7, carcinoma 6), choledochoduodenostomy (CDD) was performed in 35 patients (stones 9, chronic pancreatitis 17, carcinoma 8, and fistula 1), cholecystojejunostomy (CDJ) was performed on 48 patients (stones 1, pancreatitis 21, carcinoma 25 and stricture 1). Operative mortality was 7 per cent and morbidity occurred in 12 per cent of the patients. Symptomatic improvement was measured by relief of pain and sepsis and decrease of bilirubin and alkaline phosphatase to normal. Overall improvement was seen in 73 per cent of patients (CCE 50%, CDD 8%, CDJ 65%), 27 per cent of the patients did not improve (CCE 50%, CDD 12%, CDJ 35%), 83 per cent of the poor results were in patients with advanced malignancy. Thirty-one per cent of patients undergoing CCE required conversion to CDD or CDJ. Cholecystoduodenostomy was associated with failure in 50 per cent of patients. CCD and CDJ are safe and reliable means of relieving distal common duct obstruction due to biliary or pancreatic disease. Cholecystojejunostomy may be performed in the terminal patient with advanced carcinoma requiring a short-term biliary bypass.     

Endoscopic removal of retained stones after biliary surgery

Seventy-three patients with retained stones in the common duct after biliary surgery underwent attempted endoscopic removal at a mean interval of 39 days after surgery. Endoscopic extraction was successful in 63 patients (86 per cent). Complications occurred in 14 patients (19 per cent). The most frequent complication was haemorrhage which occurred in nine patients, four of whom required surgery; two other patients required surgery for complications. The complication rate of endoscopic sphincterotomy in recently operated patients may be higher than in the non-operated patient. Less invasive methods, such as dissolution therapy or T tube track extraction, may be preferable as they are associated with less risk. Endoscopic sphincterotomy should be reserved for patients in whom these alternative techniques fail or are inappropriate.     

Sepsis in the management of complicated biliary disorders

Postoperative sepsis developed in 72 per cent of 25 patients with noncalculous proximal biliary tract obstruction. Six episodes of shock and one death resulted. Twenty-eight per cent of septic events occurred despite the administration of prophylactic antibiotics. The incidence of septic complications was similar regardless of the biliary drainage procedure used. Despite the advent of broad spectrum antibiotics and improved surgical techniques for biliary decompression, sepsis remains a serious and frequent complication in patients with chronic bile duct obstruction.     

Clinical indications and accuracy of gray scale ultrasonography in the patient with suspected biliary tract disease

One hundred patients with suspected biliary tract disease underwent gray scale cholecystosonography (GSCS) and had diagnostic confirmation by oral cholecystogram (OCG) and/or operation. Ultrasonography demonstrated the gallbladder in 94 of the 100 patients; 2 patients had had previous cholecystectomy and 3 of the 4 remaining patients had documented stones with no confirmation of a nonvisualizing OCG in the other patient. Among the 88 patients with OCG, GSCS findings correlated in 91 per cent (2 per cent false-positive; 7 per cent false-negative). Among the 43 operative patients, GSCS was proven correct in 91 per cent (no false positive; 9 per cent false-negative). Of 12 patients with jaundice GSCS correlated with operative findings in 75 per cent (no false-positive; 25 per cent false-negative). Diagnostic errors occurred in patients with very small biliary calculi, particularly when a single stone was impacted in the cystic duct. Failure to identify the gallbladder with ultrasound signifies probable cholelithiasis in the patient without previous cholecystectomy. On the basis of this experience, we conclude that (1) GSCS is most useful when jaundice or acute illness precludes conventional studies; (2) GSCS provides an inexpensive, quick, accurate means of diagnosing cholelithiasis with a very high specificity (97 per cent) and moderate sensitivity (88 per cent); and (3) GSCS is the optimal diagnostic procedure for evaluating the biliary tract in the acutely ill, jaundiced, vomiting, allergic, and/or pregnant patient.     

Morbidity and mortality of common bile duct exploration

This retrospective study reviews the complications which occurred in 257 patients who had supraduodenal exploration of the common bile duct in one hospital during a 15-year period. One hundred and eighteen patients (46 per cent) developed complications: septic and cardiorespiratory complications were most common, occurring in 19.5 per cent and 16.7 per cent of patients respectively. Postoperative retained stones were detected in 37 patients (14 per cent), causing complications in 54 per cent. Peroperative postexploratory cholangiography did not significantly reduce the incidence of this problem. None of the 12 patients who had postexploratory choledochoscopy had retained stones. Five patients (1.9 per cent) died, three of whom had duct procedures in addition to supraduodenal exploration and two of whom had retained stones. It is concluded that common bile duct exploration has a high associated morbidity, particularly due to sepsis and retained stones.     

Surgical pathology at early elective operation for suspected acute gallstone pancreatitis: preliminary report of a prospective clinical trial

Fifty-five patients presenting with acute abdominal symptoms and found to be hyperamylasaemic underwent early biliary tract investigation, giving 31 patients in whom the presence of gallstones was suspected. In accordance with the protocol of a randomized controlled trial of early elective biliary tract surgery for patients suspected of having acute gallstone pancreatitis, 19 of these patients underwent laparotomy at a mean of 6.9 days after emergency admission. In this group operation showed that four patients had biliary tract stones and pancreatitis; ten patients had calculous cholecystitis (53 per cent) but no stigmata of pancreatitis; four patients had pancreatitis but no stones; one had a negative laparotomy. None of this group was found to have ampullary obstruction due to an impacted stone. Biliary tract investigations carried out during the first week following admission were unhelpful or misleading in 14 out of the whole group of 55 patients, and in all of those patients (11 per cent) who died or required surgical intervention during the same hospital admission. There appears to be a pathological heterogeneity among patients diagnosed as 'gallstone pancreatitis' on clinical and biochemical grounds alone.     

Gallbladder sepsis after stent insertion for bile duct obstruction: management by percutaneous cholecystostomy.

Of 364 patients undergoing insertion of a biliary endoprosthesis in 1989, six (1.6 per cent) developed gallbladder sepsis. Three patients had cholangiocarcinoma, two had carcinoma of the pancreas and one had a benign biliary stricture. Two of the five patients with malignancy had gallbladder stones, and the patient with a benign stricture developed stones after 3 years of stenting. Three patients developed gallbladder sepsis early after endoprosthesis insertion (less than 6 days), while in the other three it occurred late (greater than 6 months). All six patients failed to respond to antibiotics and were successfully managed by percutaneous cholecystostomy; the patient with a benign biliary stricture also had cholecystolithotomy. The gallbladder drainage tubes were removed or became dislodged at intervals varying from 2 weeks to 6 months without complications. Percutaneous cholecystostomy is the treatment of choice for gallbladder sepsis unresponsive to antibiotics in patients with a biliary endoprosthesis in situ.     

Caliceal calculi

Primary nonobstructive caliceal calculi were removed by nephrostolithotomy in 51 patients. Among the patients with caliceal stones indications for removal included pain in 36 (71 per cent), associated infection in 11 (21 per cent), progressive stone growth in 2 (4 per cent), hematuria in 1 (2 per cent) and flight status eligibility in 1 (2 per cent). Over-all, 300 patients have undergone percutaneous removal of upper urinary tract calculi, with a 97 per cent success rate. Successful removal was completed percutaneously in 49 patients (96 per cent). One patient remains asymptomatic with retained caliceal fragments and surgical stone removal was required in 1 additional patient. Complications occurred in 4 patients (8 per cent). One patient underwent transcatheter embolization of an intralobar artery to control renal bleeding. Three patients required placement of an internal Double-J ureteral stent to permit resolution of ureteral edema. Following recovery 34 of 36 patients (95 per cent) reported complete resolution of the preoperative pain for which the calculus was removed. Two patients had persistent urinary infection. The remaining patients reported no residual complaints. These observations suggest that pain and discomfort occasionally may be associated with nonobstructive caliceal calculi. Removal of caliceal calculi may permit resolution of associated discomfort in more than 90 per cent of all carefully selected patients.     

Endoscopic papillotomy: impact on community hospital treatment of common duct stones

High mortality rates reported with common bile duct exploration (CBDE), 3.4 per cent to as high as 30 per cent in re-exploration of those over 70 years of age, prompted review of endoscopic papillotomy (EP) for stone extraction in a community hospital as well as an attempt to assess its impact on the treatment of common duct stones. Endoscopic papillotomy in 237 patients had a 1.3 per cent mortality. Successful extraction of the stone occurred in 91.6 per cent of 108 patients followed for at least 2 years with no further treatment required. Morbidity and mortality was uneffected by previous biliary surgery, repeat attempts at stone extraction or EP performed prior to cholecystectomy (P greater than 0.1). The results of treatment for choledocholithiasis in 111 consecutive patients was then retrospectively reviewed to assess the impact of endoscopic papillotomy. CBDE was used initially in 79 and EP in 32 patients. Previous cholecystectomy and age biased the selection for endoscopic papillotomy (P less than 0.01). The mean ages were 57.8 years and 70.6 years (P less than 0.01), for CBDE and EP pts respectively. Age adjusted hospital stay was significantly longer for common bile duct exploration (P = 0.002). Overall, morbidity was not different between the treatment modalities (P = 0.50) and each group had one death (P = 0.23). In this community hospital, endoscopic papillotomy is safe, effective, and was reserved mainly for older patients or those with prior cholecystectomy and choledocholithiasis.(ABSTRACT TRUNCATED AT 250 WORDS)     

Long-term results and risk factors influencing outcome of major bile duct injuries following cholecystectomy

BACKGROUND: Major bile duct injuries usually need operative repair and remain a challenge even for surgeons who specialize in hepatobiliary surgery. The purpose of this study was to evaluate management and short- and long-term outcomes of patients with major complications after cholecystectomy. METHODS: Data were analysed for 54 patients who underwent operation for major bile duct injuries after cholecystectomy between January 1990 and January 2002. Univariate and multivariate analyses were performed to identify risk factors for the development of biliary complications. RESULTS: Complete follow-up data were available for all 54 patients (median duration 61.9 (range 2.6-154.3) months). All underwent Roux-en-Y hepaticojejunostomy. Three patients (6 per cent) died from biliary tract complications during follow-up. Long-term biliary complications occurred in ten patients (19 per cent). Nine patients developed biliary stricture of whom five developed secondary biliary cirrhosis. A successful long-term result was achieved in 50 (93 per cent) of 54 patients, including those who required subsequent procedures. Biliary reconstruction in the presence of peritonitis (P = 0.002), combined vascular and bile duct injuries (P = 0.029), and injury at or above the level of the biliary bifurcation (P = 0.012) were significant independent predictors of poor outcome. CONCLUSION: Successful repair of bile duct injuries after cholecystectomy can be achieved in specialized hepatobiliary units.     

Intrahepatic lithiasis. Study of thirty-six cases and review of the literature.

In 2,700 operations for biliary tract stones, intrahepatic lithiasis (stones located proximal to the confluence of the main hepatic ducts) was discovered in 36 patients (1.3 per cent). The diagnosis of intrahepatic lithiasis was determined only via intraoperative chalangiography in thirty-two cases (88.9 er cent); in 23 per cent of our cases of intrahepatic lithiasis, jaundice was never observed. This confirms that intraoperative cholangiography should be performed routinely in every case of biliary lithiasis. The removal of stones was generally performed by an indirect approach (papillostomy and/or choledochotomy). In 16.7 per cent of our cases, a direct approach was indicated. It is extremely important, after removal of calculi, to assure ample bilioenteric flow. Our surgical approach was therefore based mostly on the caliber of the biliary tract. When the tract was dilated less that 2 cm (in 20 cases), choledochohepaticotomy with papillostomy was most often performed (12 cases, 60 per cent). When the dilatation was more that 2 cm (12 cases), Roux-en-Y hepaticojejunostomy was performed in all. There was no operative mortality, although the long-term follow-up results were poor in 9.6 per cent of the cases.     

Electrohydraulic lithotripsy (EHL) for the treatment of large retained common duct stones

Retained biliary stones may be too large for extraction through the existing T-tube tract. It may be necessary to dilate the tract, crush the stones or use endoscopic papillotomy. There are reports of stones and the extracting basket becoming stuck in the T-tube tract and tract ruptures caused by extracting large stones. In this study electrohydraulic lithotripsy (EHL) is used in combination with T-tube tract choledochoscopy for the fragmentation of large stones prior to basket extraction. T-tube choledochoscopy was performed under IV sedation and sterile conditions no sooner than one month following common bile duct exploration. The Olympus 4.9-mm choledochoscope was passed through the T-tube tract to visualize the stone. A #5 Fr EHL probe was passed through the endoscope and advanced to within 1 mm of the surface of the stone. EHL discharge was started at a low energy level being increased until the spark discharges caused stone fragmentation. The resultant stone fragments were basket extracted under direct vision. The procedure was used in twelve patients with removal of all stones in eleven patients. Eight patients were treated with one endoscopic session. Because of multiple stones, two patients required two sessions and one patient four sessions. In one patient stone position prevented adequate fragmentation and endoscopic papillotomy also failed. Repeat choledochoscopy and EHL were successful. There were no complications of EHL or choledochoscopy in any of the patients. EHL was both effective and safe for fragmentation of large common duct stones when performed under direct vision using a choledochoscope.     

Surgical versus endoscopic management of common bile duct stones.

The charts of all patients with common bile duct (CBD) stones admitted to Virginia Mason Medical Center between January 1, 1981 and July 31, 1986 were reviewed to define current methods of management and results of operative versus endoscopic therapy. Two hundred thirty-seven patients with CBD stones were treated. One hundred thirty patients had intact gallbladders. Of these patients, 76 (59%) underwent cholecystectomy and common bile duct exploration (CBDE) while 54 (41%) underwent endoscopic papillotomy (EP) only. Of the 107 patients admitted with recurrent stones after cholecystectomy, all but five were treated with EP. The overall mortality rate was 3.0%. Complications, success, and death rates were all similar for CBDE and EP, but the complications of EP were often serious and directly related to the procedure (GI hemorrhage, 6; duodenal perforation, 5; biliary sepsis, 4; pancreatitis, 1). Patients undergoing EP required significantly shorter hospitalization than those undergoing CBDE. Multivariate analysis showed that age greater than 70 years, technical failure, and complications increased the risk of death, regardless of procedure performed. Twenty-one per cent of those undergoing EP with gallbladders intact eventually required cholecystectomy. The conclusion is that the results of EP and CBDE are similar, and the use of EP has not reduced the mortality rates of this disease.     

Clinical experience of extracorporeal shock wave lithotripsy for cystine calculi

Thirty patients (16 men and 14 women) with cystine urinary stones were treated by extracorporeal shock wave lithotripsy (Dormer HM-3) from December 1984 through October 1989. The average patient age was 35.2 years with a range of 14 to 59 years. Seventy per cent of these subjects had had previous open surgical operations for stones. The cases consisted of 7 ureteral stones and 37 renal stones, including 15 staghorn calculi. An average of 1.3 session of ESWL was carried out to treat ureteral stones. Thirty-seven renal units with renal stone required 96 sessions of lithotripsy (average 2.6 sessions per unit). Seven patients with ureteral stones required auxiliary procedures, i.e., one transurethral lithotripsy (TUL), two percutaneous nephrostomies (PNS) and one open surgery. Thirty-seven renal stones, including staghorn calculi was treated by ESWL and auxiliary treatment of 21 TUL procedures, one PNS, 16 PNL procedures and one chemical chemolysis. Successful fragmentation (residual debris less than or equal to 4 mm) was achieved in 85.7% of ureteral stones, 90.9% of renal stones and 73.3% of staghorn calculi. The stone free rates of patients with ureteral stones, renal stones and staghorn calculi were 71.4%, 50.0% and 53.5%, respectively, at 3 months after ESWL. No serious complications were seen in this series. Fever above 38.5 degrees C was the most common complications (13.5%). Ureteral perforation was encountered once in TUL procedures. Transfusion and selective arterial embolization were needed for one case treated by PNL procedures. Although cystine stone is harder to be fragmented by ESWL than other stone composition, ESWL and endourology may be effective and safe procedures for cystine stone patients.(ABSTRACT TRUNCATED AT 250 WORDS)     

Surgical morbidity and mortality in one hundred and twenty-nine patients with obstructive jaundice

One hundred and twenty-nine jaundiced patients were operated upon for the relief of benign and malignant bile duct obstruction during a 10-year period, 1977-86. The overall mortality was 4.7 per cent but increased to 9.1 per cent in patients with a serum bilirubin greater than 300 mumol/l. In all, 46.5 per cent of patients had a rise in postoperative creatinine but renal dysfunction occurred in only 4.7 per cent. Wound infection developed in 3.1 per cent of patients and appeared unrelated to infected bile; 3.9 per cent of patients were treated for postoperative septicaemic episodes. The low morbidity and mortality observed suggests that preoperative biliary drainage need not be considered in routine surgical practice if simple measures to maintain urine flow and prevent postoperative sepsis are used.