Clin. Radiol. (1976) 27, 123-127 TRANSIENT
OBSTRUCTION OF THE COMMON FOLLOWING ITS EXPLORATION
BILE DUCT
B. M A N , L. K R A U S , S. P I K I E L N Y and S. H O R O D N I C I A N O
From the Department of Surgery 'A' and the Department of Radiology, Meir Hospital, Kfar Sara, Israel, and University of Tel Aviv Medical School and Faculty of Continuing Medical Education Failure o f the contrast medium to enter the d u o d e n u m during the operative cholangiog r a p h y following the c o m m o n bile duct exploration and instrumentation m a y be caused by transient obstruction o f the c o m m o n bile duct. It is attributed to spasm and oedema o f the sphincter choledochus o f B o y d e n and n o t o f the sphincter o f Oddi. The knowledge o f the possibility o f the pseudo-obstruction o f the c o m m o n bile duct following its exploration m a y save the surgeon f r o m unnecessary re-exploration and performing sphincterotomy or choledochoduodenostomy. The exploration is unnecessary if, during the c o m m o n duct exploration, the dilators and the catheter passes easily into the d u o d e n u m and on the cholangiogram the obstructed area is smooth and there is no filling defect. A normal cholangiogram performed 8-10 days following the operation proves that the obstruction was transient and not caused by calculus stricture or tumour.
][NTRA-OPERATIVEcholangiography t h r o u g h the Ttube following exploration of the c o m m o n bile duct is a very important step to prevent the overlooking or incomplete removal o f stones. Unfortunately this procedure m a y be falsely interpreted in cases in which the contrast medium fails to enter the duodenum. In most cases, the immediate re-exploration of the c o m m o n bile duct is unnecessary if the surgeon is aware of the phenomenon o f pseudo-obstruction o f the c o m m o n bile duct which follows its exploration and instrumentation. Such obstruction m a y be transient and resolve several days following the operation. It is caused by oedema or spasm or both, of the choledochal sphincter o f Boyden (1957). If, during exploration of the c o m m o n bile duct, the dilators and catheter pass easily into the duodenum, the following intraoperative cholangiogram through the T-tube shows obstruction and the obstructed area is s m o o t h and there is no filling defect, then there is no need for re-exploration o f the c o m m o n bile duct. N o r m a l cholangiogram m a y be anticipated 8-10 days following the operation.
We present our experience in 470 bile duct operations performed from 1963 to 1973. One hundred and sixty-three explorations of the common bile duct were performed and in 112 patients, calculi were found. In 21 cases, pseudoobstruction of the bile duct appeared (13 ~). Our technique of the exploration followed by operative cholangiography is as follows: the common bile duct is opened and initially calculi are removed by milking of the duct. Then the duct is flushed through the catheter, and when the surgeon feels that the calculi are removed, the metal catheters are passed into the duodenum and the sphincter is dilated. Then the Fogarty catheter is passed, inflated and pulled back to remove any stone if stdl present. Sometimes spoons, and on rare occasions forceps are used. Following exploration of the hepatic ducts a T-drain is inserted and the check cholangiogram is performed before the wound is closed. Three films are taken after injection of 5, 7 and 15ram of the contrast medium (Diodrast 35~). The amount of the contrast medium is increased if the common duct is dilated. CASE REPORTS
Case 1. - O.E., 59-year-old woman without previous history of gallbladder disease was operated because of jaundice of two weeks' duration. On 10 July 1967 the gallbladder containing stones was removed. One calculus was removed through the choledochotomy from a dilated common bile duct. There was free passage of the metal catheter No. 18F into the duodenum. On check post-choledochotomy cholangiogram through the T-tube, homogenous filling of the bile duct was demonstrated, but no contrast material appeared PATIENTS AND TECHNIQUE in the duodenum (Fig. 1A). The cholangiogram through the The intra-operative cholangiogram through the T-tube T-tube performed ten days following the operation showed following exploration is a routine procedure in our depart- normal passage of the contrast medium into the duodenum ment. and reflux into the pancreatic duct (Fig. 1B). 123
124
CLINICAL RADIOLOGY
Case 2. - S.K., 57-year-old woman with 24 years' long history of the gallbladder disease with no jaundice, was operated on 2 February 1969. The gallbladder containing stones was removed. The dilated common duct was opened but no stones were found. The passage of the metal catheter No. 18F was free into the duodenum. On the check postcholedochotomy cholangiogram no contrast material was demonstrated in the duodenum. There was clear cut-off of the distal part of the common bile duct (Fig. 2A). The postoperative cholangiogram performed 11 days after the operation was normal with passage of the contrast medium into the duodenum (Fig. 2B). Case 3. - A.K., 56-year-old woman suffered from right upper abdominal pain for three years. On intravenous cholangiogram, calculi in the gallbladder and the common bile duct were disclosed. On 6 June 1969 the gallbladder was excised and several small calculi were removed through the choledochotomy. The metal catheter No. 18F passed freely into the duodenum. On check post-choledochotomy chol-
angiogram, there was homogenous opacification of the bile duct but no contrast material entered the duodenum (Fig. 3A). The post-operative cholangiogram through the T-tube performed nine days following the operation was normal and the contrast material was demonstrated in the duodenum (Fig. 3B). Case 4. - Sixty-seven-year-old woman with 13 years' long history of gallbladder disease and transient jaundice was operated on 15 June 1974. The gallbladder full of stones was removed. The operative cholangiogram through the cystic duct demonstrated several calculi and free passage of the contrast medium into the duodenum (Fig. 4A). Multiple calculi were removed through the choledochotomy and the metal catheter No. 18F passed freely into the duodenum. On check post-choledochotomy cholangiograrn no calcuh were demonstrated, but no passage of the contrast material into the duodenum (Fig. 4B). The post-operative cholanglogram performed ten days after the operation was normal and demonstrated reflux into the pancreatic duct (Fig. 4c).
FIG. 1 A. The check post-choledochotomy cholangiogram shows no calculi; no contrast medium is demonstrated in the duodenum. There is clear cut-off of the contrast medium at the distal part of the common duct. B. The post-operative eholangiogram is normal, the contrast medium is demonstrated in the duodenum and there is a reflux into the pancreatic duct.
TRANSIENT O B S T R U C T I O N OF THE COMMON BILE D U C T F O L L O W I N G ITS E X P L O R A T I O N
FIG. 2 A. The check post-choledochotomycholangiogram shows no calculi, but conelike, cut-off cessation of the contrast material and no passage into the duodenum. B. The post-operative cholangiogram is normal. There is clear passage of the contrast medium into the duodenum.
125
FIG. 3 A. The check post-choledochotomycholangiogram shows no calculi, but no passage of the contrast medium into the duodenum. There is smooth fingerlike cut-off cessation of the contrast medium in the distal part of the common duct. B. Post-operative cholangiogram is normal, the contrast medium passes into the duodenum.
126
CLINICAL
DISCUSSION Among 21 cases of pseudo-obstruction of the common bile duct, calculi had been found and removed in 16 cases. It seems that in these cases an additional trauma of removing the stones from the transit zone in the c o m m o n bile duct to the duodenum results in increased spasm and oedema. Similarly to the observations of Watkins (1973), Ginsburg et aL (1967) and Isaacs and Boves (1960), no reflex to the pancreatic duct was demonstrated when the contrast medium was arrested. In all our cases, normal emptying was demonstrated in cholangiograms 8-10 days following the operation and in six of these cases, pancreatic duct reflux appeared. No retained stones were disclosed. This fact supports the thesis that the obstruction is proximal to
RADIOLOGY
the sphincter of Oddi and is caused by spasm and oedema of the choledochal sphincter of Boyden. According to Boyden, as the bile and the pancreatic ducts enter the duodenal wall, they are invested by a layered sheath. This consists primarily of the musculus proprius of sphincter character, which is anchored to the choledocho-duodenal junction by auxiliary fibres derived from or attached to the intestinal musculature. Functionally the most important element is the sphincter choledochus which lines the submucosal segment of the bile duct for a distance of more than 5 m m and is located 1-2 cm proximal to the sphincter of Oddi. Tonic contraction of the sphincter choledochus is responsible for the normal filling of the gallbladder; its relaxation permits the discharge of the bile into the
FIG. 4 A. Intra-operative transcystic cholangiogram shows several calculi in the common bile duct and free passage of the contrast medium into the duodenum. B. The check post-choledochotomy cholangiogram shows clear cut-off cessation of the contrast medium in the distal part of the common bile duct and no passage of the contrast material into the duodenum. c. The post-operative cholangiogram is normal, the contrast material passes into the duodenum and there is reflux into the pancreatic duct.
TRANSIENT OBSTRUCTION OF THE COMMON BILE DUCT FOLLOWING ITS EXPLORATION intestine. Surrounding the end of the papilla is a terminal musculature consisting of the sphincter ampullae or of a sphincter papillae of Oddi, depending upon whether both ducts open into the ampulla or separately. Contracture of the former may result in reflux of the bile into the pancreatic duct; contraction of the latter would impede the outflow of juices in both ducts. In the 56 check post-choledochotomy cholangiograms presented by Ginsburg et al. (1967), there were 26 instances in which the contrast medium did not enter the duodenum, an incidence of almost 50~. In the series of Watkins (1973) of 162 cholangiograms, 14 failed to empty ( 9 ~ ) ; Saypol and Berenbaum (1965) reported eight cases of pseudo-obstruction. Among our 163 cases, 21 failed to empty (13 ~). Ginsburg et al. (1967) advise to perform a transcystic cholangiogram before exploration of the common duct. A normal transcystic
127
cholangiogram makes it likely that the subsequent post-exploratory arrest of the medium is due to operative manipulation. REFERENCES BOYDEN, E.
A. (1957). The anatomy of the choledochoduodenal junction in man. Surgery, Gynecologyand Obstetrics, 104, 641-652. GrNSBUR6,L., GEFVEN,A. & FRIEDMAN,H. (1967). Pseudoobstruction following post-choledochotomy cholangiography. Annals of Surgery, 166, 83-89. ISAACS,J. P. & BorEs, M. D. (1960). Technique and evaluation of operative cholangiography. Surgery, Gynecology and Obstetrics, 111, 103-107. SAYPOL,G. M. & BERENBAt~M,S. L. (1965). Boyden's (choledochal) sphincter: a radiographic enigma and its clinical significance. Exhibit American Medical Association Convention, NYC. WATraNS, G. L. (1973). The completion cholangiogram: failure to empty due to pseudo-obstruction. Surgery, 74, 650-653.
OBSTRUCTION OF THE COMMON FOLLOWING ITS EXPLORATION
BILE DUCT
B. M A N , L. K R A U S , S. P I K I E L N Y and S. H O R O D N I C I A N O
From the Department of Surgery 'A' and the Department of Radiology, Meir Hospital, Kfar Sara, Israel, and University of Tel Aviv Medical School and Faculty of Continuing Medical Education Failure o f the contrast medium to enter the d u o d e n u m during the operative cholangiog r a p h y following the c o m m o n bile duct exploration and instrumentation m a y be caused by transient obstruction o f the c o m m o n bile duct. It is attributed to spasm and oedema o f the sphincter choledochus o f B o y d e n and n o t o f the sphincter o f Oddi. The knowledge o f the possibility o f the pseudo-obstruction o f the c o m m o n bile duct following its exploration m a y save the surgeon f r o m unnecessary re-exploration and performing sphincterotomy or choledochoduodenostomy. The exploration is unnecessary if, during the c o m m o n duct exploration, the dilators and the catheter passes easily into the d u o d e n u m and on the cholangiogram the obstructed area is smooth and there is no filling defect. A normal cholangiogram performed 8-10 days following the operation proves that the obstruction was transient and not caused by calculus stricture or tumour.
][NTRA-OPERATIVEcholangiography t h r o u g h the Ttube following exploration of the c o m m o n bile duct is a very important step to prevent the overlooking or incomplete removal o f stones. Unfortunately this procedure m a y be falsely interpreted in cases in which the contrast medium fails to enter the duodenum. In most cases, the immediate re-exploration of the c o m m o n bile duct is unnecessary if the surgeon is aware of the phenomenon o f pseudo-obstruction o f the c o m m o n bile duct which follows its exploration and instrumentation. Such obstruction m a y be transient and resolve several days following the operation. It is caused by oedema or spasm or both, of the choledochal sphincter o f Boyden (1957). If, during exploration of the c o m m o n bile duct, the dilators and catheter pass easily into the duodenum, the following intraoperative cholangiogram through the T-tube shows obstruction and the obstructed area is s m o o t h and there is no filling defect, then there is no need for re-exploration o f the c o m m o n bile duct. N o r m a l cholangiogram m a y be anticipated 8-10 days following the operation.
We present our experience in 470 bile duct operations performed from 1963 to 1973. One hundred and sixty-three explorations of the common bile duct were performed and in 112 patients, calculi were found. In 21 cases, pseudoobstruction of the bile duct appeared (13 ~). Our technique of the exploration followed by operative cholangiography is as follows: the common bile duct is opened and initially calculi are removed by milking of the duct. Then the duct is flushed through the catheter, and when the surgeon feels that the calculi are removed, the metal catheters are passed into the duodenum and the sphincter is dilated. Then the Fogarty catheter is passed, inflated and pulled back to remove any stone if stdl present. Sometimes spoons, and on rare occasions forceps are used. Following exploration of the hepatic ducts a T-drain is inserted and the check cholangiogram is performed before the wound is closed. Three films are taken after injection of 5, 7 and 15ram of the contrast medium (Diodrast 35~). The amount of the contrast medium is increased if the common duct is dilated. CASE REPORTS
Case 1. - O.E., 59-year-old woman without previous history of gallbladder disease was operated because of jaundice of two weeks' duration. On 10 July 1967 the gallbladder containing stones was removed. One calculus was removed through the choledochotomy from a dilated common bile duct. There was free passage of the metal catheter No. 18F into the duodenum. On check post-choledochotomy cholangiogram through the T-tube, homogenous filling of the bile duct was demonstrated, but no contrast material appeared PATIENTS AND TECHNIQUE in the duodenum (Fig. 1A). The cholangiogram through the The intra-operative cholangiogram through the T-tube T-tube performed ten days following the operation showed following exploration is a routine procedure in our depart- normal passage of the contrast medium into the duodenum ment. and reflux into the pancreatic duct (Fig. 1B). 123
124
CLINICAL RADIOLOGY
Case 2. - S.K., 57-year-old woman with 24 years' long history of the gallbladder disease with no jaundice, was operated on 2 February 1969. The gallbladder containing stones was removed. The dilated common duct was opened but no stones were found. The passage of the metal catheter No. 18F was free into the duodenum. On the check postcholedochotomy cholangiogram no contrast material was demonstrated in the duodenum. There was clear cut-off of the distal part of the common bile duct (Fig. 2A). The postoperative cholangiogram performed 11 days after the operation was normal with passage of the contrast medium into the duodenum (Fig. 2B). Case 3. - A.K., 56-year-old woman suffered from right upper abdominal pain for three years. On intravenous cholangiogram, calculi in the gallbladder and the common bile duct were disclosed. On 6 June 1969 the gallbladder was excised and several small calculi were removed through the choledochotomy. The metal catheter No. 18F passed freely into the duodenum. On check post-choledochotomy chol-
angiogram, there was homogenous opacification of the bile duct but no contrast material entered the duodenum (Fig. 3A). The post-operative cholangiogram through the T-tube performed nine days following the operation was normal and the contrast material was demonstrated in the duodenum (Fig. 3B). Case 4. - Sixty-seven-year-old woman with 13 years' long history of gallbladder disease and transient jaundice was operated on 15 June 1974. The gallbladder full of stones was removed. The operative cholangiogram through the cystic duct demonstrated several calculi and free passage of the contrast medium into the duodenum (Fig. 4A). Multiple calculi were removed through the choledochotomy and the metal catheter No. 18F passed freely into the duodenum. On check post-choledochotomy cholangiograrn no calcuh were demonstrated, but no passage of the contrast material into the duodenum (Fig. 4B). The post-operative cholanglogram performed ten days after the operation was normal and demonstrated reflux into the pancreatic duct (Fig. 4c).
FIG. 1 A. The check post-choledochotomy cholangiogram shows no calculi; no contrast medium is demonstrated in the duodenum. There is clear cut-off of the contrast medium at the distal part of the common duct. B. The post-operative eholangiogram is normal, the contrast medium is demonstrated in the duodenum and there is a reflux into the pancreatic duct.
TRANSIENT O B S T R U C T I O N OF THE COMMON BILE D U C T F O L L O W I N G ITS E X P L O R A T I O N
FIG. 2 A. The check post-choledochotomycholangiogram shows no calculi, but conelike, cut-off cessation of the contrast material and no passage into the duodenum. B. The post-operative cholangiogram is normal. There is clear passage of the contrast medium into the duodenum.
125
FIG. 3 A. The check post-choledochotomycholangiogram shows no calculi, but no passage of the contrast medium into the duodenum. There is smooth fingerlike cut-off cessation of the contrast medium in the distal part of the common duct. B. Post-operative cholangiogram is normal, the contrast medium passes into the duodenum.
126
CLINICAL
DISCUSSION Among 21 cases of pseudo-obstruction of the common bile duct, calculi had been found and removed in 16 cases. It seems that in these cases an additional trauma of removing the stones from the transit zone in the c o m m o n bile duct to the duodenum results in increased spasm and oedema. Similarly to the observations of Watkins (1973), Ginsburg et aL (1967) and Isaacs and Boves (1960), no reflex to the pancreatic duct was demonstrated when the contrast medium was arrested. In all our cases, normal emptying was demonstrated in cholangiograms 8-10 days following the operation and in six of these cases, pancreatic duct reflux appeared. No retained stones were disclosed. This fact supports the thesis that the obstruction is proximal to
RADIOLOGY
the sphincter of Oddi and is caused by spasm and oedema of the choledochal sphincter of Boyden. According to Boyden, as the bile and the pancreatic ducts enter the duodenal wall, they are invested by a layered sheath. This consists primarily of the musculus proprius of sphincter character, which is anchored to the choledocho-duodenal junction by auxiliary fibres derived from or attached to the intestinal musculature. Functionally the most important element is the sphincter choledochus which lines the submucosal segment of the bile duct for a distance of more than 5 m m and is located 1-2 cm proximal to the sphincter of Oddi. Tonic contraction of the sphincter choledochus is responsible for the normal filling of the gallbladder; its relaxation permits the discharge of the bile into the
FIG. 4 A. Intra-operative transcystic cholangiogram shows several calculi in the common bile duct and free passage of the contrast medium into the duodenum. B. The check post-choledochotomy cholangiogram shows clear cut-off cessation of the contrast medium in the distal part of the common bile duct and no passage of the contrast material into the duodenum. c. The post-operative cholangiogram is normal, the contrast material passes into the duodenum and there is reflux into the pancreatic duct.
TRANSIENT OBSTRUCTION OF THE COMMON BILE DUCT FOLLOWING ITS EXPLORATION intestine. Surrounding the end of the papilla is a terminal musculature consisting of the sphincter ampullae or of a sphincter papillae of Oddi, depending upon whether both ducts open into the ampulla or separately. Contracture of the former may result in reflux of the bile into the pancreatic duct; contraction of the latter would impede the outflow of juices in both ducts. In the 56 check post-choledochotomy cholangiograms presented by Ginsburg et al. (1967), there were 26 instances in which the contrast medium did not enter the duodenum, an incidence of almost 50~. In the series of Watkins (1973) of 162 cholangiograms, 14 failed to empty ( 9 ~ ) ; Saypol and Berenbaum (1965) reported eight cases of pseudo-obstruction. Among our 163 cases, 21 failed to empty (13 ~). Ginsburg et al. (1967) advise to perform a transcystic cholangiogram before exploration of the common duct. A normal transcystic
127
cholangiogram makes it likely that the subsequent post-exploratory arrest of the medium is due to operative manipulation. REFERENCES BOYDEN, E.
A. (1957). The anatomy of the choledochoduodenal junction in man. Surgery, Gynecologyand Obstetrics, 104, 641-652. GrNSBUR6,L., GEFVEN,A. & FRIEDMAN,H. (1967). Pseudoobstruction following post-choledochotomy cholangiography. Annals of Surgery, 166, 83-89. ISAACS,J. P. & BorEs, M. D. (1960). Technique and evaluation of operative cholangiography. Surgery, Gynecology and Obstetrics, 111, 103-107. SAYPOL,G. M. & BERENBAt~M,S. L. (1965). Boyden's (choledochal) sphincter: a radiographic enigma and its clinical significance. Exhibit American Medical Association Convention, NYC. WATraNS, G. L. (1973). The completion cholangiogram: failure to empty due to pseudo-obstruction. Surgery, 74, 650-653.
