Primary Common Duct Stones PRAKASH C. SAHARIA, M.B., F.R.C.S.(Edin.), GEORGE D. ZUIDEMA, M.D., JOHN L. CAMERON, M.D.

Thirty patients were identified as having primary common duct stones. Criteria for diagnosis included at least a two year symptom free interval following cholecystectomy; soft, light brown stones or sludge present in the common duct; and the absence of a long cystic duct remnant or a biliary stricture from the previous surgery. The average age of the 30 patients was 66 years. The interval between cholecystectomy and the diagnosis of primary common duct stones averaged 12 years. Acute cholangitis was a frequent mode of presentation. At the time of surgery the bile duct was often dilated out of proportion to the serum bilirubin. In only one of the 30 patients was ampullary stenosis present. Twenty-six of the 30 patients had only stone extraction and insertion of a T tube for treatment of their primary common duct stones. Twenty-two of the 26 were followed for an average of four years and nine months with no evidence of recurrent stones in 82% (18/22). Four developed recurrent primary common duct stones one, five, five, and 7 years later. It is concluded that most patients with primary common duct stones do well after stone extraction alone.

T HE IDENTIFICATION of primary common duct stones by gross morphology at the time of surgery can be difficult. Furthermore, if the gallbladder is still in place, or only recently removed, origin of the stone in the common duct is impossible to prove. With this background it is not surprising that the incidence of primary common duct stones in series of common duct explorations varies widely.1'2'12 In addition, once the surgeon decides a primary common duct stone is present, treatment is controversial. In an effort to identify patients who with some certainty could be said to

have primary common duct stones, patients undergoing common duct exploration over a 24 year period were

reviewed. Clinical presentation, operative findings, surgical treatment, and long term followup are reported. Clinical Material Patients undergoing common duct exploration at The Johns Hopkins Hospital between 1952 and 1975 were reviewed. Patients were classified as having primary common duct stones if they met all of the following criteria: (1) previous cholecystectomy with or without Presented at the Annual Meeting of the Southern Surgical Association, December 5-8, 1976, Palm Beach, Florida.

From the Department of Surgery, The Johns Hopkins Medical Institutions, Baltimore, Maryland

common duct exploration; (2) at least a two year asymptomatic period following their initial biliary tract surgery; (3) the finding of soft, easily crushable, light brown stones or sludge in the common duct; and finally, (4) no evidence of a long cystic duct remnant or a biliary stricture resulting from the prior surgery. Of 758 patients undergoing common duct exploration during this interval, 30 (4%) met these criteria for primary common duct stones. Many others were felt possibly to have primary common duct stones because of the operative description of soft, earth-like or muddy stones. However, because the gallbladder was still in, or had been removed during the prior two years, origin in the common duct could be disputed and they were excluded. Average age of these 30 patients was 66 years. Twenty-three were female and 7 were male. Twenty-five were caucasian and five were negro. The time interval between the initial biliary tract surgery and the finding of a primary common duct stone varied from two years to 36 years and averaged 12 years (Table 1). Because of the long interval between operative procedures, data from the first operation frequently were not available. Of the 10 patients on whom information was available, 8 were known to have undergone common duct exploration. Stones were found in the common duct in five of the 8. Post operative T tube cholangiograms were normal in all 8 patients. Sixteen of the 30 patients presented with acute cholangitis, 15 were clinically jaundiced, and 21 had right upper quadrant pain. The average duration of symptoms was 39 weeks. The delay in diagnosis probably resulted from not considering biliary tract pathology because of the long symptom-free interval since cholecystectomy. At the time of presentation with primary common duct stones, 24 (80%o) of the 30 patients had serum bilirubin elevations. Twenty-two (81%) of the 27 patients who pre-operatively had SGOT determinations had elevations, and 19 (86%) of 22 had 598

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TABLE 1. Patients with Primary Common Duct Stones

tients

Age (years)

Sex

Race

Asymptomatic Interval After Cholecystectomy

30

46-86 Average 66

23 Female 7 Male

25 White 5 Black

2-36 years Average 12 years

Pa-

SGPT elevations. Twenty-four (89o) of the 27 patients in whom the alkaline phosphatase level was measured had elevations. Twenty-one of the 30 patients had serum amylase determinations on admission and in 19%o it was found to be elevated (Table 2). Clinical Management Prior to surgery an attempt was made in 25 of the 30 patients to visualize the biliary tree radiographically. Of the 20 patients undergoing intravenous cholangiography, common duct stones were demonstrated in 12. In one additional patient a dilated duct was seen. In 7 patients the biliary tree was not visualized. Four patients underwent endoscopic retrograde cholangiography and in three patients it was successful in demonstrating common duct stones (Figs. la and b). In the fourth patient the duct could not be cannulated. One patient had a transhepatic cholangiogram performed and common duct stones were visualized. All 30 patients were operated upon, and common duct stones or sludge were found in all. In each instance they were described as soft and easily crushable, usually being brown or earth-like in color. Sludge was also frequently present in the duct. In 12 patients only a single stone was found in the common duct at the time of exploration. In 16 patients multiple stones were found in the common duct and in two patients only sludge was encountered. The common duct was described as of normal caliber in three patients. In 19 patients the duct diameter was dilated to 2 cm; in two patients to 3 cm; and in two patients to 4 cm. The duct size was not mentioned in four patients. Often the duct appeared to be dilated out of proportion to the serum bilirubin. For instance, in the two patients with ducts measuring 4 cm, the average serum bilirubin was 2.0 mgto. In 29 of the 30 patients the surgeon described the ampulla as easily allowing the passage of a dilator or probe. In only one instance did the surgeon feel that ampullary stenosis was present (Table 3). After common duct exploration and stone extraction, 26 of the 30 patients had only T tube drainage. Three patients underwent side-to-side choledochoduodenostomies, and one had a sphincteroplasty performed. There were no operative or hospital deaths.

599

Clinical Followup Of the 26 patients with primary common duct stones treated by stone extraction and T tube drainage only, followup was available for 22 (Table 4). Followup ranged from 8 months to 12 years and averaged four years and 9 months. Eighteen of the patients remained well over an average period of four years and 10 months and developed no subsequent symptoms suggesting biliary tract disease. Four of the 22 patients treated only by stone extraction and T tube drainage developed subsequent problems. Three patients required reoperation for recurrent stones one, five, and seven years after the initial primary common duct stone extraction. One patient underwent a choledochoduodenostomy, one a sphincteroplasty, and the third a choledochojejunostomy at reexploration. The fourth patient died of sepsis five years after primary stone extraction, and at post mortem recurrent stones were found. For the four patients undergoing additional procedures at the time of primary stone extraction, followup averaged three years and 6 months. All have done well with no suggestion of recurrent biliary tract disease. Discussion It is generally accepted that the majority of stones found in the common bile duct have their origin in the gallbladder.' In most large series of common duct explorations the gallbladder is still in place and .contains stones at the time of common duct extractions.2,7 In addition, following cholecystectomy very few patients subsequently develop common duct stones.6 Nevertheless, some stones clearly are formed in the common duct. Reported cases of common duct stones found in patients with congenital absence of the gallbladder provides absolute proof of this.5"4 Proving that a stone had its origin in the common duct in the presence of a gallbladder, however, is difficult. Madden," who has focused a great deal of attention on primary common duct stones in recent years, feels they can be accurately identified by morphologic features alone. He states TABLE 2. Liver Function and Amylase Determinations in 30 Patients with Primary Common Duct Stones Liver Function Test

Patients

Bilirubin SGOT SGPT Alk Phos Amylase

30 27 22 27 21

Elevated 24 22 19 24 4

(80%o) (81%) (86%) (89%) (9Wo)

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SAHARIA, ZUIDEMA AND CAMERON

FIG. la. Endoscopic retrograde cholangiogram (ERC) of a 74 year old female demonstrating a dilated duct with sludge in the distal end near the ampulla. She had been asymptomatic for 4 years following her cholecystectomy prior to developing primary common duct stones.

that characteristically the stone formed in the common bile duct is solitary, ovoid, light brown in color, soft and easily crushable. Whenever such a stone is found in the common duct, whether the gallbladder is in or out, or contains stones or not, Madden feels this is proof of common duct origin. Another possibility, however, is that a small gallbladder stone passed into the common duct and subsequently accumulated biliary sludge. Others have used the time of identification of the common duct stone in relation to cholecystectomy as the basis by which to ascribe site of origin.6 When a common duct stone is found with the gallbladder still in, it is thought most likely to have migrated from the gallbladder. If the stone is found within one or possibly two years of the time of cholecystectomy, then it is considered a retained gallbladder stone missed at the time of operation. A common duct stone found over one or two years post cholecystectomy, however, is usually felt to be a primary common duct stone formed in the biliary tree after cholecystectomy. Because of the different methods of identifying or defining primary common duct stones, the reported incidence varies widely. In a series of 120 patients undergoing extraction of common duct stones at the Lahey Clinic,2 only three were felt to have definitely formed in the common duct. Millbourn13 in a series of 22 patients found to have common duct stones

Ann. Surg. * May 1977

weeks to years following cholecystectomy, felt that new stone formation in the common duct was probable in only five. Bartlett,' in a group of 26 patients from the Massachusetts General Hospital requiring a second common duct exploration, felth that 21 were definitely retained gallbladder stones, and five were recurrent or primary common duct stones. In contrast, in a series of 107 common duct explorations in which stones were found, Madden11 has reported an incidence of primary common duct stones of 56%. He claims that when identified on morphologic grounds, primary common duct stones are more common than stones in the common duct that have migrated from the gallbladder. In over 50%o of the patients identified in Madden's series as having primary common duct stones, the gallbladder was still in place at the time of common duct exploration. The pathogenesis of primary common duct stone formation is obscure. It has been shown experimentally that obstruction and stasis will result in stone formation in animals.8 Stones and sludge are also seen clinically above a benign or malignant bile duct stricture. Madden11 has pointed out that 47% of the patients in his series with primary commmon duct stones had ampullary stenosis, a condition found in only 10% of the patients with secondary or gallbladder common duct stones. This also suggests stasis as an etiology. In our present series, however, only one of the 30 patients was felt to have any significant ampullary stenosis. This is despite the fact that marked common duct dilatation out of proportion

FIG. lb. ERC of a 67 year old man demonstrating multiple common duct stones. His gallbladder had been removed 20 years earlier.

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to the serum bilirubin was often found. It is possible that primary common duct stones are stasis stones, aothough not always the result of mechanical obstruction. Conceivably the large dilated ducts may represent abnormal functional dilatation following cholecystectomy, rather than arising secondary to mechanical obstruction by ampullary stenosis, or produced by the common duct stone itself. This abnormal functional dilatation could then result in stasis and stone formation. Almost certainly lithogenic bile is also a major factor. In most series primary common duct stone formation has not occurred in the absence of prior stone formation in the gallbladder. As with all other aspects of primary common duct stones, treatment is controversial. Many surgeons have not recommended anything beyond stone removal. Madden,'1 however, is a strong advocate of side-toside choledochoduodenostomy, presumably to reduce stasis in the duct. Because there has been so much variation in identifying patients with primary common duct stones, evaluation of any form of treatment is difficult. In addition, reports of long term followup of patients treated for primary common duct stones are virtually non-existent. For this reason we set out to define a group of patients who with a high degree of certainty had primary common duct stones, in order to obtain long term followup and evaluate their treatment. To do this, we combined both the morphologic and time criteria in defining primary common duct stones. To be included, a patient had to have had a previous cholecystectomy followed by a period of at least two years of being asymptomatic. It is conceivable that a retained gallbladder stone could remain silent for this period of time, but it is unlikely. In addition, at the time of reexploration, the common duct stone had to have the morphologic features of a stasis stone; that is, soft, light brown, TABLE 3. Operative Findings in 30 Patients with Primary Common Duct Stones

Common Duct Stones

Solitary Multiple Sludge

12 16 2 Common Duct Size

Normal 2 cm 3 cm 4 cm Unknown

3 19

2 2 4 Ampullary Stenosis

Present Absent

29

601

TABLE 4. Followup Data on 26 Patients Operated on for Primary Common Duct Stones

Stone extraction only Stone extraction plus duct drainage procedure

Patients with Followup

Length of Followup

Asymptomatic

Recurrence

22

57 months

18

4

4

42 months

4

easily crushable, and often sludge-like. Finally, there could be no evidence of a long cystic duct remnant or of a stricture resulting from the prior biliary tract surgery, although ampullary stenosis could be present. Using these strict criteria, only 30 of the 758 patients with common duct explorations were acceptable. Some or many of the remaining patients could have had primary common duct stones, but to avoid adding questionable cases, no patient not meeting all criteria was included. The average interval between the onset of biliary tract symptoms and the diagnosis of a primary common duct stone in our series was 39 weeks. One of the reasons for this long delay was probably the fact that all patients had previously undergone cholecystectomy and had an average interval of 12 years of being symptom free. In many instances this probably diverted the physician's attention away from the biliary tract. The 38 week delay in diagnosis might also explain why over one-half of the patients presented to the hospital with cholangitis. It has been noted in the past in a series of patients with acute cholangitis from this hospital, that primary common duct stones and acute cholangitis are frequently associated.15 The presenting liver chemistries were characteristic for biliary tract disease and cholangitis, with the majority having an elevated bilirubin, alkaline phosphatase, and transaminases. As noted by Madden," however, the degree of dilatation of the common bile duct was often out of proportion to the usually low level of bilirubin elevation. Preoperative cholangiography was often successful in demonstrating a common duct stone. We now feel that endoscopic retrograde cholangiography is the method of choice, and that an intravenous study should be performed only when endoscopic cholangiography is unsuccessful. Occasionally, when complete obstruction is present, a percutaneous study will be indicated. Even though Madden" has stated that 68% of primary common duct stones will be solitary, in our series 60o were multiple or contained sludge. Knowing this from a good cholangiogram pre-operatively is helpful. If one performs endoscopic or percutaneous

602

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SAHARIA, ZUIDEMA AND CAMERON

cholangiography in these patients, surgery should be performed within 24 hours if stones have been demonstrated in order to avoid potential lifethreatening sepsis.3 Twenty-six of the 30 patients in the present series had only cholodochotomy with stone extraction and insertion of a T tube. Most of these patients were elderly, and many had presented just a few days earlier with acute cholangitis. In addition, in none of these 26 patients was there evidence of mechanical obstruction. For these reasons, only stone extraction was performed. Four of these patients were lost to followup. The remaining 22 patients have been followed for periods ranging from 8 months to 12 years. Eighteen (82%) of these 22 patients have had no evidence of recurrent biliary tract symptoms. Average followup for these 18 patients is four years and 10 months. Four (18%) of the 22 patients have had recurrent common duct stones. Three presented with symptoms of cholangitis and required reoperation one, five, and 7 years after their initial primary common duct stone extraction. Each patient had a procedure performed at the second stone extracion to more adequately drain his duct. The fourth patient was an 81 year old female who presented with severe sepsis five years after initial primary common duct stone extraction. At post mortem recurrent primary common duct stones were found. This was the only biliary tract related death in the entire series. It is clear from this followup that the majority of patients with primary common duct stones will do well for at least a five year period after stone extraction alone. This should be kept in mind by the surgeon at the time of operation if the patient is elderly and ill, possibly just recovering from cholangitis, and not able to tolerate a long operative procedure. If in addition either pre-operative or operative cholangiography has ruled out multiple stones, stone extraction and T tube insertion alone is acceptable. The chance of remaining symptom free for five years will be over 80%o. One has to keep in mind that the initial symptom free interval between cholecystectomy and primary common duct stone formation averaged 12 years. In contrast, if one is dealing with a young healthy individual with a potential long life span ahead, and possibly with multiple stones, an additional procedure should be considered. Since most patients in our series did not have mechanical obstruction, the additional procedure is to allow any possible subsequent recurrent stones to pass, rather than to decompress an obstructed duct. Madden"1 has recommended side-to-side choledochoduodenostomy for this purpose. If the duct is large enough to allow at least a 2 cm anastomosis, cholangitis after-

Surg. * May 1977

wards will occur rarely.49 Cases continue to be reported, however, with calculi and debris filling the distal "defunctionalized" common duct and this represents a valid cricitism of the procedure. 10"16 The operation is quicker, safer, and probably more effective than performing a choledochojejunostomy to a Roux-en-Y loop. Another option is sphincteroplasty as performed by Jones.10 Functionally this results in a side-to-side choledochoduodenostomy performed from within the duodenum. This eliminates the distal defunctionalized common duct segment and for that reason is preferred. The operation is performed frequently in our institution for retained or multiple common duct stones, and should be seriously considered in the patient with primary common duct stones who is a candidate for a procedure in addition to stone extraction. In many instances, however, when clinical circumstances dictate, the surgeon may safely and correctly decide to perform only stone extraction.

References 1. Bartlett, M. K.: Retained and Recurrent Common Duct Stones. Am. Surg., 38:63, 1972. 2. Colcock, B. P. and Liddle, H. U.: Common-Bile Duct Stones. N. Engl. J. Med., 258:264, 1958. 3. Davis, J. L., Milligan, F. D. and Cameron, J. L.: Septic 4.

5. 6.

7.

8.

9. 10. 11.

12.

13. 14.

15. 16.

Complications Following Endoscopic Retrograde Cholangiopancreatography. Surg. Gynecol. Obstet., 140:365, 1975. Degenshein, G. A.: Choledochoduodenostomy: An 18 Year Study of 175 Consecutive Cases. Surgery, 76:319, 1974. Gerwig, W. H., Jr., Countryman, L. K. and Gomez, A. C.: Congenital Absence of the Gallbladder and Cystic Duct; Report of 6 Cases. Ann. Surg., 153:113, 1961. Glenn, F.: Post Cholecystectomy Choledocholithiasis. Surg. Gynecol. Obstet., 134:249, 1972. Glenn, F. and Beil, A. R.: Choledocholithiasis Demonstrated at 586 Operations. Surg. Gynecol. Obstet., 118:499, 1964. Imamoglu, K., Perry, J. F., Jr. and Wangensteen, 0. H.: Experimental Production of Gallstones by Incomplete Stricture of the Common Bile Duct. Surgery, 42:623, 1957. Johnson, A. G. and Stevens, A. E.: Importance of the Size of the Stoma in Choledocho-duodenostomy. Gut, 10:68, 1969. Jones, S. A.: Sphincteroplasty (Not Sphincterotomy) in the Treatment of Biliary Tract Disease. Surg. Clin. North Am., 53:1123, 1973. Madden, J. L.: Common Duct Stones; Their Origin and Surgical Management. Surg. Clin. North Am., 53:1095, 1973. Madden, J. L., Vanderheyden, L. and Kandalaft, S.: The Nature and Surgical Significance of Common Duct Stones. Surg. Gynecol. Obstet., 126:3, 1968. Millbourn, E.: On Reoperation for Choledocholithiasis. Acta Chir. Scand., 99:285, 1950. Rains, A. J. H.: Congenital Absence of the Gallbladder; Cholangiography; Gallstone Solvents. Br. J. Surg., 39:37, 1951. Saharia, P. C. and Cameron, J. L.: Clinical Management of Acute Cholangitis. Surg. Gynecol. Obstet., 142:369, 1976. Wright, N. L.: Evaluation of the Results of Choledochoduodenostomy. Br. J. Surg., 55:33, 1968.

Primary common duct stones.

Primary Common Duct Stones PRAKASH C. SAHARIA, M.B., F.R.C.S.(Edin.), GEORGE D. ZUIDEMA, M.D., JOHN L. CAMERON, M.D. Thirty patients were identified...
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