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Surgical interventions for bile duct stones H-J. KR;iMLING V. LANGE F. W. SCHILDBERG G. HEBERER
For many decades the treatment of choice for bile duct stones has been common bile duct exploration (CBDE). Almost 20 years ago endoscopic sphincterotomy and stone extraction were introduced by Classen and Demling (1974). Since then surgery has been increasingly replaced by endoscopy . In recent years other non-operative methods such as direct electrohydraulic or laser lithotripsy (Burhenne, 1975; El1 et al, 1988), dissolution therapy (Thistle et al, 1980), extracorporeal shock wave lithotripsy (ESWL) (Sauerbruch et al, 1989) and percutaneous transhepatic (PTC) stone removal (Stokes and Clouse, 1990) have further widened the variety of therapeutic approaches. Some of these, such as ESWL or PTC, have been introduced into routine clinical practice, but others remain experimental. The development of new forms of non-operative treatment continues. In surgery, the laparoscopic approach to bile duct stones may lead to new concepts (Bailey and Zucker, 1991; Berci et al, 1991). We find ourselves in a dramatically changing field. Thus, it seems difficult to outline general rules for bile duct stone therapy that are valid for longer periods of time. Therefore, this contribution focuses mainly on the differential surgical approach and on surgical techniques for treatment of bile duct stones, based on the literature and on the experience of 3365 patients who underwent cholecystectomy or who were treated for bile duct stones (n = 420) from September 1977 to December 1991. SURGICAL
APPROACH
The decision to undertake surgical treatment of bile duct stones is based on several factors of the disease. The most important are: (1) the diagnosis of solitary duct stones or concomitant gallbladder stones or gallbladder disorders; (2) the timepoint of diagnosis, i.e. before, during or after surgery; and (3) the inflammatory complications of stone disease such as cholangitis and pancreatitis. Other factors such as localization of stones (hepaticolithiasis) or primary surgery compared with reintervention also influence the surgical approach, but are less common. Baillitre’s Clinical GastroenterologyVol. 6, No. 4, November 1992 ISBN 0-7020-1625X
819 Copyright 0 1992, by Bailliere Tindall All rights of reproduction in any form reserved
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Solitary bile duct stones or concomitant gallbladder stones/disease Solitary bile duct stones with unaffected and stone-free gallbladder or situations following cholecystectomy present with specific signs and symptoms due to cholangitis or duct obstruction. The treatment of these cases is widely accepted as a domain of endoscopic therapy (Paumgartner et al, 1988). Only in cases in which endoscopy fails or is not feasible (patients with Billroth II resections), or in which additional non-operative measures (e.g. ESWL) are not successful, are open (or laparoscopic) surgical procedures indicated. The majority of bile duct stones present as simultaneous cholecystocholedocholithiusis because most duct stones originate from the gallbladder (Sieg et al, 1986). Of course, a history of jaundice as well as pathological laboratory findings or recurrent biliary pain necessitate further evaluation of the patient. Sonography or computed tomographic scan are of limited value in detecting bile duct stones (Hagenmiiller and Schwacha, Chapter 10). Preoperative infusion cholangiography with tomography is favoured by French surgeons, with good results (Cuschieri et al, 1991). Endoscopic retrograde cholangiography (ERC) has the highest sensitivity and specificity for detection of common duct stones, but is not used routinely. In all patients with bile duct stones who lack specific signs and symptoms no specific diagnostic procedures such as ERC are usually carried out. These patients present with unexpected calculi at the time of surgery with a rate of about 5% (Kitahama et al, 1986; Thompson and Bennion, 1988; Berci et al, 1991). During the period of open surgery 15% of our patients had bile duct stones at the time of surgery. Neoptolemos et al (1987b) reported that about 18% of their patients presented with concomitant bile duct stones during cholecystectomy. Although these values may be lower due to more extensive diagnostic approaches for laparoscopic cholecystectomy, decision-making often has to be done during surgery. The surgeon has to decide whether he or she will treat the patient exclusively by surgery, by endoscopy including secondary methods (e.g. lithotripsy), or by combined concepts (Heberer et al, 1989). On the other hand, the surgeon’s therapeutic approach will differ when bile duct stones are diagnosed before rather than after surgery.
Timepoint of diagnosis The variety of diagnostic procedures and their value in detection of bile duct stones is reviewed extensively by Hagenmiiller and Schwacha (Chapter 10). Diagnostic measures are discussed here only when necessary from the surgical standpoint. Patients with preoperative diagnosis of bile duct stones Simultaneous cholecystocholedocholithiasis normally requires cholecystectomy and stone removal from the bile duct. Open cholecystectomy with CBDE and stone removal was the choice of treatment for many decades.
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However, additional CBDE may increase the mortality rate of simple cholecystectomy to 2.4% (Schildberg and Pratschke, 1990). There are series with no or very low mortality rates in younger patients (Heberer et al, 1990; Pappas et al, 1990), but mortality rates increase to 8% especially in old patients, emergency operations and in case of inflammatory complications (McSherry and Glenn, 1980; Johnson and Hosking, 1987). Endoscopic treatment of common bile duct stones is reported to have an overall mortality rate of 1% (Johnson and Hosking, 1987). Therefore, open surgery cannot be recommended as the routine practice today. Appropriate selection of patients has to be carried out if modern treatment modalities are to be employed. Open chofecystectomy following preoperative endoscopic retrograde cholangiography (ERC), sphincterotomy and stone removal has been reported to be a useful combination (Heinerman et al, 1989; Stiegmann et al, 1989) although Neoptolemos et al (1987a) could not demonstrate significant advantages in a randomized study. Today, preoperative ERC with sphincterotomy and subsequent laparoscopic cholecystectomy is widely accepted (Stiegmann et al, 1989; Zucker, 1991a). Even in old patients and those at high risk, this has proved to be a successful concept (Figure 1). The development of laparoscopic cholecystectomy and laparoscopic extraction of common bile duct stones offers another modern alternative approach (Bailey and Zucker, 1991; Berci et al, 1991; Jacobs et al, 1991). Postoperative sphincterotomy and stone removal would be indicated for those cases in which laparoscopic measures had failed previously. In exceptional cases ERC and sphincterotomy may be performed in very old patients and/or those at high risk without subsequent gallbladder removal. In a recently published series 191 patients were treated endoscopically for common bile duct stones, the gallbladder being left in situ (Hill et al, 1991). Only ten patients (5%) were consecutively cholecystectomizedmost frequently within 1 year-for symptoms or acute complications arising from gallbladder stones. None of the patients died from biliary disease. However, about 25% of patients died within 3 years from non-biliary pathology, usually from cardiovascular disorders. It was concluded that this group of patients did not need further gallbladder surgery. However, the new approach of laparoscopic cholecystectomy with lower morbidity and mortality rates might allow removal of the gallbladder even in critically ill patients, and thus definitively cure gallstone disease, which minimizes the risk of symptoms and complications. For example, biliary pancreatitis does recur in more than 50% of patients when the stone-bearing gallbladder is left in situ (Windsor, 1990). Our current practice is to perform ERC and sphincterotomy in all patients undergoing laparoscopic cholecystectomy in whom choledocholithiasis is suspected. Of 500 patients, 56 (11.27) o underwent preoperative ERC for suspected common duct stones (Table 1). In 13 patients calculi were discovered and successfully removed by sphincterotomy. In the postoperative course only eight patients (1.6%), who had not undergone preoperative ERC, had evidence of retained common bile duct stones. This was fewer than expected and may be due to the selection of patients.
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Table 1. Laparoscopic cholecystectomy: incidence of common bile duct calculi and removal in 500 patients before and after surgery (July 1990 to April 1992). No. of patients Preoperative ERCP Common bile duct stones
56 (11.2%) 13 (2.6%)
Postoperative ERCP Common bile duct stones
8 (1.6%) 8 (1.6%)
Patients with intraoperative
diagnosis of bile duct stones
Intraoperative diagnostic for common bile duct stones is advocated to be performed routinely by intraoperative cholangiography (Jacobs et al, 1986; Kitahama et al, 1986; Berci et al, 1991; Zucker, 1991a,b), although its value has been discussed controversially during the past two decades. Unnecessary intraoperative cholangiography may be avoided by using a scoring system of five objective factors: size of common bile duct diameter 3 12mm, gallstones < lOmm, advanced age, chronic or acute cholecystitis, and past history of biliary colic. Patients with these findings routinely undergo intraoperative cholangiography. The risk of all other patients to have common duct stones is only about 2%) and therefore cholangiography can be avoided (Huguier et al, 1991). Thus, the selective use of intraoperative cholangiography in cholecystectomy can be both safe and inexpensive (Pasquale and Nauta, 1989). This approach is suitable for open as well as laparoscopic cholecystectomy. Cuschieri et al (1991) reported on the European experience with intraoperative cholangiography in laparoscopic procedures. Surgeons were using routine and selective cholangiography in 25% and 75% of cases, respectively. Zucker (1991b) and Soper (1991) estimated that imaging studies are important in at least 30% of all procedures in order to exclude choledocholithiasis, to visualize ductal anatomy, to identify other abnormalities, and thus minimize the risk of injury. Small defects up to 3mm in diameter on the cholangiogram normally represent gas bubbles or small calculi that will pass through the ampulla without difficulty. If there is no history or pathological sign of obstruction in these cases, no choledocholithotomy should be performed (Zucker, 1991b). By this approach unnecessary CBDE can be avoided and subsequent morbidity and mortality rates may be decreased to the range of simple cholecystectomy. As mentioned above, in a non-selected group of patients with gallbladder stones about 5% of patients will present with unexpected calculi during intraoperative diagnostic measures (Kitahama et al, 1986; Thompson and Bennion, 1988). In this group the choice of treatment has to be made during the ongoing procedure. In the case of open cholecystectomy we would proceed with open bile duct exploration, as has been our practice in past years. This approach still seems reasonable, especially in patients with no risk factors, in those with large, completely obstructing stones (in whom a subsequent ERCP could fail and
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would carry potentially grave consequences) or when postoperative ERCP would not be feasible for technical reasons or because of altered anatomy (Billroth II resection). Our experience since 1977 includes 420 patients with open cholecystectomy and CBDE. During the past 6 years we have achieved a reasonably low rate of 4.4% retained stones and an operative mortality rate of 1.1% (Table 2). These values are comparable to those obtained with endoscopic procedures. Table 2. Open common bile duct exploration: retained and residual stones and hospital mortality rate in 420 patients (October 1977 to December 1991). 1977-1984 1985-1991 1977-1991
n
Retained stones (%)
Mortality rate (%)
240 180 420
6.3 4.4 5.5
2.5 1.1 1.9
If unsuspected common bile duct stones are discovered during laparoscopit cholecystectomy they may be removed by: (1) conversion to open cholecystectomy and open exploration of the common duct (which is not recommended as a routine procedure); (2) postoperative ERCP and stone removal. As mentioned above, this procedure has a very high success rate in up to 90% of cases. In the experience of Zucker (1991b) with more than 400 laparoscopic biliary duct procedures, open CBDE had to be performed in only one individual in whom ERCP had failed; (3) translaparoscopic clearance of calculi can also be achieved. Using Jluoroscopic guidance, a stone basket or Fogarty catheter may be passed through the cystic duct into the common bile duct and the stone subsequently extracted (Petelin, 1991; Zucker, 1991b). Another approach is to dilate the cystic duct and pass a small flexible nephrourethroscope through the cystic duct into the common bile duct. Under direct vision, the stone can be extracted using a basket, placed through the biopsy channel of the endoscope (Zucker, 1991b; Carroll et al, 1992). Very large stones are fragmented using intracorporeal electrohydraulic or laser lithotripsy (Arregui et al, 1992). In the near future, devices will undoubtedly be designed to simplify a combined endoscopic and laparoscopic management of common bile duct stones. In case of inaccessible cystic duct the common bile duct can be opened directly and closed over a T tube using laparoscopic techniques (Jacobs et al, 1991). Alternatively an ‘antegrade’ sphincterotomy using a pappilotome passed from above can be performed as in open surgery (Lange et al, 1989). Beside standard methods and the above-mentioned sophisticated techniques transduodenal papilloplasty or bilio-enteric bypass are rare procedures in the operative treatment of common duct stones. We had to perform these procedures in only 5.2% of all patients with choledocholithiasis.
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Patients with postoperative diagnosis of bile duct stones
Retained common duct stones may be found in about 5% of patients in the postoperative course of cholecystectomy (DenBesten and Berci, 1986). If the T tube is still in place retained stones may be extracted by using percutaneous radiological approaches. Although Burhenne (1980) reported a success rate greater than 90%, this technique has not gained general acceptance. The reason may be the time delay (several weeks) necessary to form an appropriate T tube tract. Today, retained or recurrent stones are removed effectively by endoscopit sphincterotomy (Johnson and Hosking, 1987; Sauerbruch et al, 1989; Heberer et al, 1990). Approximately 10% of calculi cannot be removed mechanically by ERCP. At our hospital these patients undergo extracorporeal lithotripsy. In those, about 80-90% of common bile ducts can be cleared of stones. Our patients were included in a multicentre study by Sauerbruch et al (1989) in which 113 patients with stones not removable by endoscopy underwent ESWL. Eighty-six per cent of patients were treated successfully. Other non-operative treatment methods are availabile (see chapters 3,4, 5, 6, 11) and are used in the same manner as in preoperative therapy for cholecystodocholithiasis or for the treatment of solitary duct stones (Paumgartner et al, 1988). In the future, laparoscopic removal of bile duct stones following cholecystectomy may be another treatment choice for retained or recurrent stones. Open surgical reintervention to clear the common bile duct of calculi by CBDE will only rarely be necessary (Zucker, 1991b). Transduodenal sphincteroplasty or choledochoduodenostomy or choledochojejunostomy are best reserved for the few patients with non-extractable impacted stones, ampullary or bile duct stenosis, or recurrent common bile duct stones in whom all the above-mentioned techniques have failed.
Inflammatory
complications
Indications may vary depending on inflammatory complications of gallstone disease. Preoperatively diagnosed bile duct stones with concomitant pancreatitis or cholangitis should be treated primarily by endoscopy and show good results (Paumgartner et al, 1988; Shemesch et al, 1990). Complications of emergency surgery are much higher in these patients (Leese et al, 1986; Neoptolemos et al, 1988). In severe cholecystitis the exact anatomy of the bile system is often hard to define and duodenotomy may be too dangerous an approach to the biliary system. As Jacobs et al (1986) demonstrated, acute cholecystitis is accompanied by a high percentage of common duct stones (12.4%), which are mostly diagnosed intraoperatively. There is no urgent need to remove these calculi from the common duct at any price. Postoperative ERC and papillotomy will clear the common duct sufficiently in most cases. If it is unclear whether endoscopy can be performed in a patient after operation (e.g. in the case of a Billroth II resection) antegrade sphincterotomy may be indicated (Lange et al, 1989).
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SURGICAL
METHODS
Open common bile duct exploration
(CBDE)
Our technique of open CBDE for cholecystocholedocholithiasis is briefly summarized: after preparation of the gallbladder the common duct is cannulated via the cystic duct. If cholangiography reveals calculi, the gallbladder is removed first and the cystic duct is ligated. Then, distal to this point the peritoneal layer is opened and the common bile duct is identified. A longitudinal stab incision is made and enlarged using angular scissors. Two holding sutures are used to stretch out the anterior wall in order to mark the incision clearly and avoid injury to the duct and its posterior wall during the procedure (Figure 1). Exploration and cleaning of the bile duct should always be performed bimanually. After mobilization of the duodenum the surgeon’s left hand holds the retroduodenal part of the common bile duct and the duodenal papillary region. Thus, surgical instruments that are placed by the right hand into the common duct can be guided safely. Stones may be felt by this approach as well. The removal of stones is performed with Fogarty catheters and copious rinsing (Figure 1). Forceps are seldom necessary to remove calculi adherent to the wall. Careful handling of these instruments is necessary to prevent injury of the bile duct. Flexible or rigid cholangioscopy is routinely applied to ensure total clearing
b Figure 1. Technique of open common bile duct exploration. The gallbladder has been removed and the cystic duct is ligated (a). A Fogarty catheter is brought alongside the stone to the ampulla. The stone is drawn back to the common duct incision by the balloon and removed. A T tube is inserted (b) and the choledochotomy is closed by interrupted sutures.
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of the common bile duct, the hepatic duct junction and the preampullary region. The procedure is always completed by inserting a rubber T tube. The closure of the incision is then performed by interrupted sutures with 5 x 0 monofilament material. Final assessment of complete stone removal is revealed by cholangiography via the inserted T tube. Using this approach we were able to achieve reasonable results with respect to clearance of the common bile duct, morbidity and mortality (Table 2). We left stones in 5.5% of 420 cases of CBDE. This rate is concordant with data reported in the literature where 6.1% of stones were left in a series of 1812 patients (Schildberg and Pratschke, 1990). This value corresponds with the results of endoscopic techniques when previous endoscopic failure (10% depending on patient selection) is treated by additional methods such as demonstrated by Sauerbruch et al (1989) who applied ESWL for nonremovable common bile duct stones. In our patients 3.6% of the stones were overlooked due to inadequate technique whereas in the remaining 1.9% they were left in situ on purpose to be removed later via endoscopy. The latter group of patients presented with local problems such as cholecystitis or were at high risk because of age or concomitant disease. In our opinion, the most important point in achieving good clearance is the routine use of intraoperative cholangioscopy, as our own results and a review of the recent literature have shown very clearly (Schildberg and Pratschke, 1990). Only 1% of stones were left in this series of 878 patients. The morbidity of CBDE which led to retreatment procedures is shown in Table 3. Of 420 patients, 3.3% had to undergo surgical and 5.7% endoscopit reintervention. Reasons for relaparotomy were infected haematomas, bilious fistulae and stones left behind in patients after Billroth II gastrectomy. Endoscopic reinterventions were performed most often in order to remove retained and residual stones. Two bilious fistulae were stented endoscopically. One T tube was torn off and had to be removed endoscopically, and one case of papillary stenosis was treated by sphincterotomy. Table 3. Open common bile duct exploration: surgical and endoscopic treatment of complications in 420 patients (October 1977 to December 1991). Complication
n
Infected haematoma Bile duct leakage Retained stone T tube dislocation Total
61 4 3I 1 14
Retained stone Bile duct leakage T tube dislocation Stenosis of papilla Total
20) 2 1 1 24
Treatment Relaparotomy (3.3%)
Endoscopy (5.7%)
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The mortality rate was low in our series. We noted only 1.9% in all patients and 1.1% in the last 7 years. This figure corresponds well with the results of endoscopic treatment and is lower than that in recent reports of 182 patients in a multicentre international series (DenBesten and Berci, 1986) and of 1812 CBDE procedures in a literature review (Schildberg and Pratschke, 1990), which gave mortality rates of 4.4% and 2.4%, respectively. Transduodenal
papilloplasty
There are few indications for use of this procedure in stone disease. In our experience only 16 patients (4.3%) who had CBDE and cholecystectomy as a primary operation (n = 375) needed additional papilloplasty. The reasons
b
A/ /’ ’1’ ,w’
,4 ’ /’ / x
k C
a
d
Figure 2. Technique of transduodenal papilloplasty. (a) Following supraduodenal cannulation of the common duct and localization of the papilla of Vater, a transverse or longitudinal duodenotomy is performed. (b and c) The papillary roof is dissected (11 o’clock) by diathermia. Stones can be removed by Fogarty catheters, forceps and rinsing. (d) The duodenal mucosa is sutured to the wall of the papilla. If the pancreatic duct cannot be clearly identified only lateral sutures are placed.
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were incrusted papillary concrements or papillary stenosis in most of the patients. The technique includes Kocher’s manoeuvre for duodenal mobilization. From a supraduodenal incision the common duct is cannulated, the ampulla of Vater is localized by this procedure, and a transverse or longitudinal duodenotomy is performed. The papillary sphincter is cut in its roof portion, and the duodenal mucosa is sutured with the wall of the common duct (Figure 2). The transduodenal approach reveals a high rate of bile duct clearing (Ribotta and Procacciante, 1988), as was shown in our 16 patients in whom no concrement was left. In former years papilloplasty was overused as a routine procedure in cases of suspected papillary stenosis. In these elective series this procedure was reported to be safe and effective (Ribotta and Procacciante, 1988). When applied exclusively to selected patients in whom
Figure 3. Common duct re-stenosis in a woman aged 61 years. Endoscopic retrograde cholangiogram shows prestenotic dilatation and calculus. One year previously cholecystectomy, common bile duct exploration with stone removal and dilatation therapy had been carried out. A bilio-enteric bypass procedure (choledochojejunostomy) was performed as treatment for recurrent stenosis.
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CBDE had failed a higher mortality rate may be found. In our experience, 1 of 16 patients died. Bilio-enteric bypass This procedure has very rare applications in common duct stone surgery. Only when the wide variety of endoscopic, laparoscopic and open surgical options has failed should it be applied. The most common reasons are recurrent stones and distal stenosis of the common duct (Figure 3), impacted distal stones, or periampullary duodenal diverticula (Gliedmann, 1988). In our experience only 7 of 420 patients (1.7%) underwent this procedure (Table 4). The best methods seem to be choledochojejunostomy and, less often, hepaticojejunostomy (Roux-en-Y). Retrograde infections are a problem with all bilio-enteric bypass procedures, mostly in choledochoduodenostomy which we do not recommend. Cholecystojejunostomy should be avoided whenever possible because of poor functional results. Table 4. Open common bile duct exploration (CBDE): primary and secondary procedures, and additional measures in cases of unsuccessful CBDE in 420 patients (October 1977 to December 1991). n
Additional
Primary surgery for cholelithiasis (CBDE and cholecystectomy)
375 (89.3%)
16 (4.3%) Transduodenal papilloplasty 6 (1.6%) Bilio-enteric bypass
Reintervention (CBDE)
45 (10.7%) 42 (10.0%) following cholecystectomy 420 (100%)
2 (4.4%) Choledochoplasty 1 (2.2%) Bilio-enteric bypass
CBDE
for cholelithiasis
procedures
SUMMARY Based on our experience of 420 common bile duct procedures for stone disease and a literature review, it is evident that treatment of common duct stones today is based on a wide variety of non-operative and surgical methods which are still being developed. The mode of treatment is basically related to the time of diagnosis. Methods also differ depending on the localization of calculi, on inflammatory complications of stone disease, and whether combined or isolated cholecystocholedocholithiasis is present. At the moment, traditional operative methods as well as newly developed advanced techniques have to be evaluated. Selection of patients and their appropriate surgical and non-surgical treatment is an important issue to be further developed in the next few years. Therefore, therapeutic indications and definitive therapy present a much more demanding challenge for the surgeon than in the period when only open surgery was available.
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Zucker KA (1991a) Laparoscopic guided cholecystectomy with electrocautery dissection. In Zucker KA (ed.) Surgical Laparoscopy, pp 143-182. St Louis: Quality Medical Publishing. Zucker KA (1991b) Laparoscopic cholecystectomy and the patient with suspected or unsuspected choledocholithiasis. In Diseases of the Liver, Biliary Tract, and Pancreas, pp 103-105. American Congress of Surgeons, Postgraduate Course.
Surgical interventions for bile duct stones H-J. KR;iMLING V. LANGE F. W. SCHILDBERG G. HEBERER
For many decades the treatment of choice for bile duct stones has been common bile duct exploration (CBDE). Almost 20 years ago endoscopic sphincterotomy and stone extraction were introduced by Classen and Demling (1974). Since then surgery has been increasingly replaced by endoscopy . In recent years other non-operative methods such as direct electrohydraulic or laser lithotripsy (Burhenne, 1975; El1 et al, 1988), dissolution therapy (Thistle et al, 1980), extracorporeal shock wave lithotripsy (ESWL) (Sauerbruch et al, 1989) and percutaneous transhepatic (PTC) stone removal (Stokes and Clouse, 1990) have further widened the variety of therapeutic approaches. Some of these, such as ESWL or PTC, have been introduced into routine clinical practice, but others remain experimental. The development of new forms of non-operative treatment continues. In surgery, the laparoscopic approach to bile duct stones may lead to new concepts (Bailey and Zucker, 1991; Berci et al, 1991). We find ourselves in a dramatically changing field. Thus, it seems difficult to outline general rules for bile duct stone therapy that are valid for longer periods of time. Therefore, this contribution focuses mainly on the differential surgical approach and on surgical techniques for treatment of bile duct stones, based on the literature and on the experience of 3365 patients who underwent cholecystectomy or who were treated for bile duct stones (n = 420) from September 1977 to December 1991. SURGICAL
APPROACH
The decision to undertake surgical treatment of bile duct stones is based on several factors of the disease. The most important are: (1) the diagnosis of solitary duct stones or concomitant gallbladder stones or gallbladder disorders; (2) the timepoint of diagnosis, i.e. before, during or after surgery; and (3) the inflammatory complications of stone disease such as cholangitis and pancreatitis. Other factors such as localization of stones (hepaticolithiasis) or primary surgery compared with reintervention also influence the surgical approach, but are less common. Baillitre’s Clinical GastroenterologyVol. 6, No. 4, November 1992 ISBN 0-7020-1625X
819 Copyright 0 1992, by Bailliere Tindall All rights of reproduction in any form reserved
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Solitary bile duct stones or concomitant gallbladder stones/disease Solitary bile duct stones with unaffected and stone-free gallbladder or situations following cholecystectomy present with specific signs and symptoms due to cholangitis or duct obstruction. The treatment of these cases is widely accepted as a domain of endoscopic therapy (Paumgartner et al, 1988). Only in cases in which endoscopy fails or is not feasible (patients with Billroth II resections), or in which additional non-operative measures (e.g. ESWL) are not successful, are open (or laparoscopic) surgical procedures indicated. The majority of bile duct stones present as simultaneous cholecystocholedocholithiusis because most duct stones originate from the gallbladder (Sieg et al, 1986). Of course, a history of jaundice as well as pathological laboratory findings or recurrent biliary pain necessitate further evaluation of the patient. Sonography or computed tomographic scan are of limited value in detecting bile duct stones (Hagenmiiller and Schwacha, Chapter 10). Preoperative infusion cholangiography with tomography is favoured by French surgeons, with good results (Cuschieri et al, 1991). Endoscopic retrograde cholangiography (ERC) has the highest sensitivity and specificity for detection of common duct stones, but is not used routinely. In all patients with bile duct stones who lack specific signs and symptoms no specific diagnostic procedures such as ERC are usually carried out. These patients present with unexpected calculi at the time of surgery with a rate of about 5% (Kitahama et al, 1986; Thompson and Bennion, 1988; Berci et al, 1991). During the period of open surgery 15% of our patients had bile duct stones at the time of surgery. Neoptolemos et al (1987b) reported that about 18% of their patients presented with concomitant bile duct stones during cholecystectomy. Although these values may be lower due to more extensive diagnostic approaches for laparoscopic cholecystectomy, decision-making often has to be done during surgery. The surgeon has to decide whether he or she will treat the patient exclusively by surgery, by endoscopy including secondary methods (e.g. lithotripsy), or by combined concepts (Heberer et al, 1989). On the other hand, the surgeon’s therapeutic approach will differ when bile duct stones are diagnosed before rather than after surgery.
Timepoint of diagnosis The variety of diagnostic procedures and their value in detection of bile duct stones is reviewed extensively by Hagenmiiller and Schwacha (Chapter 10). Diagnostic measures are discussed here only when necessary from the surgical standpoint. Patients with preoperative diagnosis of bile duct stones Simultaneous cholecystocholedocholithiasis normally requires cholecystectomy and stone removal from the bile duct. Open cholecystectomy with CBDE and stone removal was the choice of treatment for many decades.
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However, additional CBDE may increase the mortality rate of simple cholecystectomy to 2.4% (Schildberg and Pratschke, 1990). There are series with no or very low mortality rates in younger patients (Heberer et al, 1990; Pappas et al, 1990), but mortality rates increase to 8% especially in old patients, emergency operations and in case of inflammatory complications (McSherry and Glenn, 1980; Johnson and Hosking, 1987). Endoscopic treatment of common bile duct stones is reported to have an overall mortality rate of 1% (Johnson and Hosking, 1987). Therefore, open surgery cannot be recommended as the routine practice today. Appropriate selection of patients has to be carried out if modern treatment modalities are to be employed. Open chofecystectomy following preoperative endoscopic retrograde cholangiography (ERC), sphincterotomy and stone removal has been reported to be a useful combination (Heinerman et al, 1989; Stiegmann et al, 1989) although Neoptolemos et al (1987a) could not demonstrate significant advantages in a randomized study. Today, preoperative ERC with sphincterotomy and subsequent laparoscopic cholecystectomy is widely accepted (Stiegmann et al, 1989; Zucker, 1991a). Even in old patients and those at high risk, this has proved to be a successful concept (Figure 1). The development of laparoscopic cholecystectomy and laparoscopic extraction of common bile duct stones offers another modern alternative approach (Bailey and Zucker, 1991; Berci et al, 1991; Jacobs et al, 1991). Postoperative sphincterotomy and stone removal would be indicated for those cases in which laparoscopic measures had failed previously. In exceptional cases ERC and sphincterotomy may be performed in very old patients and/or those at high risk without subsequent gallbladder removal. In a recently published series 191 patients were treated endoscopically for common bile duct stones, the gallbladder being left in situ (Hill et al, 1991). Only ten patients (5%) were consecutively cholecystectomizedmost frequently within 1 year-for symptoms or acute complications arising from gallbladder stones. None of the patients died from biliary disease. However, about 25% of patients died within 3 years from non-biliary pathology, usually from cardiovascular disorders. It was concluded that this group of patients did not need further gallbladder surgery. However, the new approach of laparoscopic cholecystectomy with lower morbidity and mortality rates might allow removal of the gallbladder even in critically ill patients, and thus definitively cure gallstone disease, which minimizes the risk of symptoms and complications. For example, biliary pancreatitis does recur in more than 50% of patients when the stone-bearing gallbladder is left in situ (Windsor, 1990). Our current practice is to perform ERC and sphincterotomy in all patients undergoing laparoscopic cholecystectomy in whom choledocholithiasis is suspected. Of 500 patients, 56 (11.27) o underwent preoperative ERC for suspected common duct stones (Table 1). In 13 patients calculi were discovered and successfully removed by sphincterotomy. In the postoperative course only eight patients (1.6%), who had not undergone preoperative ERC, had evidence of retained common bile duct stones. This was fewer than expected and may be due to the selection of patients.
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Table 1. Laparoscopic cholecystectomy: incidence of common bile duct calculi and removal in 500 patients before and after surgery (July 1990 to April 1992). No. of patients Preoperative ERCP Common bile duct stones
56 (11.2%) 13 (2.6%)
Postoperative ERCP Common bile duct stones
8 (1.6%) 8 (1.6%)
Patients with intraoperative
diagnosis of bile duct stones
Intraoperative diagnostic for common bile duct stones is advocated to be performed routinely by intraoperative cholangiography (Jacobs et al, 1986; Kitahama et al, 1986; Berci et al, 1991; Zucker, 1991a,b), although its value has been discussed controversially during the past two decades. Unnecessary intraoperative cholangiography may be avoided by using a scoring system of five objective factors: size of common bile duct diameter 3 12mm, gallstones < lOmm, advanced age, chronic or acute cholecystitis, and past history of biliary colic. Patients with these findings routinely undergo intraoperative cholangiography. The risk of all other patients to have common duct stones is only about 2%) and therefore cholangiography can be avoided (Huguier et al, 1991). Thus, the selective use of intraoperative cholangiography in cholecystectomy can be both safe and inexpensive (Pasquale and Nauta, 1989). This approach is suitable for open as well as laparoscopic cholecystectomy. Cuschieri et al (1991) reported on the European experience with intraoperative cholangiography in laparoscopic procedures. Surgeons were using routine and selective cholangiography in 25% and 75% of cases, respectively. Zucker (1991b) and Soper (1991) estimated that imaging studies are important in at least 30% of all procedures in order to exclude choledocholithiasis, to visualize ductal anatomy, to identify other abnormalities, and thus minimize the risk of injury. Small defects up to 3mm in diameter on the cholangiogram normally represent gas bubbles or small calculi that will pass through the ampulla without difficulty. If there is no history or pathological sign of obstruction in these cases, no choledocholithotomy should be performed (Zucker, 1991b). By this approach unnecessary CBDE can be avoided and subsequent morbidity and mortality rates may be decreased to the range of simple cholecystectomy. As mentioned above, in a non-selected group of patients with gallbladder stones about 5% of patients will present with unexpected calculi during intraoperative diagnostic measures (Kitahama et al, 1986; Thompson and Bennion, 1988). In this group the choice of treatment has to be made during the ongoing procedure. In the case of open cholecystectomy we would proceed with open bile duct exploration, as has been our practice in past years. This approach still seems reasonable, especially in patients with no risk factors, in those with large, completely obstructing stones (in whom a subsequent ERCP could fail and
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would carry potentially grave consequences) or when postoperative ERCP would not be feasible for technical reasons or because of altered anatomy (Billroth II resection). Our experience since 1977 includes 420 patients with open cholecystectomy and CBDE. During the past 6 years we have achieved a reasonably low rate of 4.4% retained stones and an operative mortality rate of 1.1% (Table 2). These values are comparable to those obtained with endoscopic procedures. Table 2. Open common bile duct exploration: retained and residual stones and hospital mortality rate in 420 patients (October 1977 to December 1991). 1977-1984 1985-1991 1977-1991
n
Retained stones (%)
Mortality rate (%)
240 180 420
6.3 4.4 5.5
2.5 1.1 1.9
If unsuspected common bile duct stones are discovered during laparoscopit cholecystectomy they may be removed by: (1) conversion to open cholecystectomy and open exploration of the common duct (which is not recommended as a routine procedure); (2) postoperative ERCP and stone removal. As mentioned above, this procedure has a very high success rate in up to 90% of cases. In the experience of Zucker (1991b) with more than 400 laparoscopic biliary duct procedures, open CBDE had to be performed in only one individual in whom ERCP had failed; (3) translaparoscopic clearance of calculi can also be achieved. Using Jluoroscopic guidance, a stone basket or Fogarty catheter may be passed through the cystic duct into the common bile duct and the stone subsequently extracted (Petelin, 1991; Zucker, 1991b). Another approach is to dilate the cystic duct and pass a small flexible nephrourethroscope through the cystic duct into the common bile duct. Under direct vision, the stone can be extracted using a basket, placed through the biopsy channel of the endoscope (Zucker, 1991b; Carroll et al, 1992). Very large stones are fragmented using intracorporeal electrohydraulic or laser lithotripsy (Arregui et al, 1992). In the near future, devices will undoubtedly be designed to simplify a combined endoscopic and laparoscopic management of common bile duct stones. In case of inaccessible cystic duct the common bile duct can be opened directly and closed over a T tube using laparoscopic techniques (Jacobs et al, 1991). Alternatively an ‘antegrade’ sphincterotomy using a pappilotome passed from above can be performed as in open surgery (Lange et al, 1989). Beside standard methods and the above-mentioned sophisticated techniques transduodenal papilloplasty or bilio-enteric bypass are rare procedures in the operative treatment of common duct stones. We had to perform these procedures in only 5.2% of all patients with choledocholithiasis.
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Patients with postoperative diagnosis of bile duct stones
Retained common duct stones may be found in about 5% of patients in the postoperative course of cholecystectomy (DenBesten and Berci, 1986). If the T tube is still in place retained stones may be extracted by using percutaneous radiological approaches. Although Burhenne (1980) reported a success rate greater than 90%, this technique has not gained general acceptance. The reason may be the time delay (several weeks) necessary to form an appropriate T tube tract. Today, retained or recurrent stones are removed effectively by endoscopit sphincterotomy (Johnson and Hosking, 1987; Sauerbruch et al, 1989; Heberer et al, 1990). Approximately 10% of calculi cannot be removed mechanically by ERCP. At our hospital these patients undergo extracorporeal lithotripsy. In those, about 80-90% of common bile ducts can be cleared of stones. Our patients were included in a multicentre study by Sauerbruch et al (1989) in which 113 patients with stones not removable by endoscopy underwent ESWL. Eighty-six per cent of patients were treated successfully. Other non-operative treatment methods are availabile (see chapters 3,4, 5, 6, 11) and are used in the same manner as in preoperative therapy for cholecystodocholithiasis or for the treatment of solitary duct stones (Paumgartner et al, 1988). In the future, laparoscopic removal of bile duct stones following cholecystectomy may be another treatment choice for retained or recurrent stones. Open surgical reintervention to clear the common bile duct of calculi by CBDE will only rarely be necessary (Zucker, 1991b). Transduodenal sphincteroplasty or choledochoduodenostomy or choledochojejunostomy are best reserved for the few patients with non-extractable impacted stones, ampullary or bile duct stenosis, or recurrent common bile duct stones in whom all the above-mentioned techniques have failed.
Inflammatory
complications
Indications may vary depending on inflammatory complications of gallstone disease. Preoperatively diagnosed bile duct stones with concomitant pancreatitis or cholangitis should be treated primarily by endoscopy and show good results (Paumgartner et al, 1988; Shemesch et al, 1990). Complications of emergency surgery are much higher in these patients (Leese et al, 1986; Neoptolemos et al, 1988). In severe cholecystitis the exact anatomy of the bile system is often hard to define and duodenotomy may be too dangerous an approach to the biliary system. As Jacobs et al (1986) demonstrated, acute cholecystitis is accompanied by a high percentage of common duct stones (12.4%), which are mostly diagnosed intraoperatively. There is no urgent need to remove these calculi from the common duct at any price. Postoperative ERC and papillotomy will clear the common duct sufficiently in most cases. If it is unclear whether endoscopy can be performed in a patient after operation (e.g. in the case of a Billroth II resection) antegrade sphincterotomy may be indicated (Lange et al, 1989).
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SURGICAL
METHODS
Open common bile duct exploration
(CBDE)
Our technique of open CBDE for cholecystocholedocholithiasis is briefly summarized: after preparation of the gallbladder the common duct is cannulated via the cystic duct. If cholangiography reveals calculi, the gallbladder is removed first and the cystic duct is ligated. Then, distal to this point the peritoneal layer is opened and the common bile duct is identified. A longitudinal stab incision is made and enlarged using angular scissors. Two holding sutures are used to stretch out the anterior wall in order to mark the incision clearly and avoid injury to the duct and its posterior wall during the procedure (Figure 1). Exploration and cleaning of the bile duct should always be performed bimanually. After mobilization of the duodenum the surgeon’s left hand holds the retroduodenal part of the common bile duct and the duodenal papillary region. Thus, surgical instruments that are placed by the right hand into the common duct can be guided safely. Stones may be felt by this approach as well. The removal of stones is performed with Fogarty catheters and copious rinsing (Figure 1). Forceps are seldom necessary to remove calculi adherent to the wall. Careful handling of these instruments is necessary to prevent injury of the bile duct. Flexible or rigid cholangioscopy is routinely applied to ensure total clearing
b Figure 1. Technique of open common bile duct exploration. The gallbladder has been removed and the cystic duct is ligated (a). A Fogarty catheter is brought alongside the stone to the ampulla. The stone is drawn back to the common duct incision by the balloon and removed. A T tube is inserted (b) and the choledochotomy is closed by interrupted sutures.
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of the common bile duct, the hepatic duct junction and the preampullary region. The procedure is always completed by inserting a rubber T tube. The closure of the incision is then performed by interrupted sutures with 5 x 0 monofilament material. Final assessment of complete stone removal is revealed by cholangiography via the inserted T tube. Using this approach we were able to achieve reasonable results with respect to clearance of the common bile duct, morbidity and mortality (Table 2). We left stones in 5.5% of 420 cases of CBDE. This rate is concordant with data reported in the literature where 6.1% of stones were left in a series of 1812 patients (Schildberg and Pratschke, 1990). This value corresponds with the results of endoscopic techniques when previous endoscopic failure (10% depending on patient selection) is treated by additional methods such as demonstrated by Sauerbruch et al (1989) who applied ESWL for nonremovable common bile duct stones. In our patients 3.6% of the stones were overlooked due to inadequate technique whereas in the remaining 1.9% they were left in situ on purpose to be removed later via endoscopy. The latter group of patients presented with local problems such as cholecystitis or were at high risk because of age or concomitant disease. In our opinion, the most important point in achieving good clearance is the routine use of intraoperative cholangioscopy, as our own results and a review of the recent literature have shown very clearly (Schildberg and Pratschke, 1990). Only 1% of stones were left in this series of 878 patients. The morbidity of CBDE which led to retreatment procedures is shown in Table 3. Of 420 patients, 3.3% had to undergo surgical and 5.7% endoscopit reintervention. Reasons for relaparotomy were infected haematomas, bilious fistulae and stones left behind in patients after Billroth II gastrectomy. Endoscopic reinterventions were performed most often in order to remove retained and residual stones. Two bilious fistulae were stented endoscopically. One T tube was torn off and had to be removed endoscopically, and one case of papillary stenosis was treated by sphincterotomy. Table 3. Open common bile duct exploration: surgical and endoscopic treatment of complications in 420 patients (October 1977 to December 1991). Complication
n
Infected haematoma Bile duct leakage Retained stone T tube dislocation Total
61 4 3I 1 14
Retained stone Bile duct leakage T tube dislocation Stenosis of papilla Total
20) 2 1 1 24
Treatment Relaparotomy (3.3%)
Endoscopy (5.7%)
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The mortality rate was low in our series. We noted only 1.9% in all patients and 1.1% in the last 7 years. This figure corresponds well with the results of endoscopic treatment and is lower than that in recent reports of 182 patients in a multicentre international series (DenBesten and Berci, 1986) and of 1812 CBDE procedures in a literature review (Schildberg and Pratschke, 1990), which gave mortality rates of 4.4% and 2.4%, respectively. Transduodenal
papilloplasty
There are few indications for use of this procedure in stone disease. In our experience only 16 patients (4.3%) who had CBDE and cholecystectomy as a primary operation (n = 375) needed additional papilloplasty. The reasons
b
A/ /’ ’1’ ,w’
,4 ’ /’ / x
k C
a
d
Figure 2. Technique of transduodenal papilloplasty. (a) Following supraduodenal cannulation of the common duct and localization of the papilla of Vater, a transverse or longitudinal duodenotomy is performed. (b and c) The papillary roof is dissected (11 o’clock) by diathermia. Stones can be removed by Fogarty catheters, forceps and rinsing. (d) The duodenal mucosa is sutured to the wall of the papilla. If the pancreatic duct cannot be clearly identified only lateral sutures are placed.
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were incrusted papillary concrements or papillary stenosis in most of the patients. The technique includes Kocher’s manoeuvre for duodenal mobilization. From a supraduodenal incision the common duct is cannulated, the ampulla of Vater is localized by this procedure, and a transverse or longitudinal duodenotomy is performed. The papillary sphincter is cut in its roof portion, and the duodenal mucosa is sutured with the wall of the common duct (Figure 2). The transduodenal approach reveals a high rate of bile duct clearing (Ribotta and Procacciante, 1988), as was shown in our 16 patients in whom no concrement was left. In former years papilloplasty was overused as a routine procedure in cases of suspected papillary stenosis. In these elective series this procedure was reported to be safe and effective (Ribotta and Procacciante, 1988). When applied exclusively to selected patients in whom
Figure 3. Common duct re-stenosis in a woman aged 61 years. Endoscopic retrograde cholangiogram shows prestenotic dilatation and calculus. One year previously cholecystectomy, common bile duct exploration with stone removal and dilatation therapy had been carried out. A bilio-enteric bypass procedure (choledochojejunostomy) was performed as treatment for recurrent stenosis.
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CBDE had failed a higher mortality rate may be found. In our experience, 1 of 16 patients died. Bilio-enteric bypass This procedure has very rare applications in common duct stone surgery. Only when the wide variety of endoscopic, laparoscopic and open surgical options has failed should it be applied. The most common reasons are recurrent stones and distal stenosis of the common duct (Figure 3), impacted distal stones, or periampullary duodenal diverticula (Gliedmann, 1988). In our experience only 7 of 420 patients (1.7%) underwent this procedure (Table 4). The best methods seem to be choledochojejunostomy and, less often, hepaticojejunostomy (Roux-en-Y). Retrograde infections are a problem with all bilio-enteric bypass procedures, mostly in choledochoduodenostomy which we do not recommend. Cholecystojejunostomy should be avoided whenever possible because of poor functional results. Table 4. Open common bile duct exploration (CBDE): primary and secondary procedures, and additional measures in cases of unsuccessful CBDE in 420 patients (October 1977 to December 1991). n
Additional
Primary surgery for cholelithiasis (CBDE and cholecystectomy)
375 (89.3%)
16 (4.3%) Transduodenal papilloplasty 6 (1.6%) Bilio-enteric bypass
Reintervention (CBDE)
45 (10.7%) 42 (10.0%) following cholecystectomy 420 (100%)
2 (4.4%) Choledochoplasty 1 (2.2%) Bilio-enteric bypass
CBDE
for cholelithiasis
procedures
SUMMARY Based on our experience of 420 common bile duct procedures for stone disease and a literature review, it is evident that treatment of common duct stones today is based on a wide variety of non-operative and surgical methods which are still being developed. The mode of treatment is basically related to the time of diagnosis. Methods also differ depending on the localization of calculi, on inflammatory complications of stone disease, and whether combined or isolated cholecystocholedocholithiasis is present. At the moment, traditional operative methods as well as newly developed advanced techniques have to be evaluated. Selection of patients and their appropriate surgical and non-surgical treatment is an important issue to be further developed in the next few years. Therefore, therapeutic indications and definitive therapy present a much more demanding challenge for the surgeon than in the period when only open surgery was available.
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