Stones in the bile duct

Duct stones may occur many years after a cholecystectomy or be related to the development of new pathology, such as infection of the biliary tree or infestation by Ascaris lumbricoides or Clinorchis sinensis. Any obstruction to the flow of bile can give rise to stasis with the formation of stones within the duct. The consequences of duct stones are either obstruction to bile flow or infection-cholangitis. Stones in the bile ducts are more often associated with infected bile (80 per cent) than are stones in the gall bladder.

Symptoms

The patient may be asymptomatic but usually has bouts of pain, jaundice and fever. The patient is often ill and feels unwell. The term ‘cholangitis’ is given to the triad of pain, jaundice and fevers sometimes known as ‘Charcot’s triad’.

Signs

Tenderness may be elicited in the epigastrium and the right hypochondrium. In the jaundiced patient it is useful to remember Courvoisier’s law — ‘in obstruction of the common bile duct due to a stone, distension of the gall bladder seldom occurs; the organ usually is already shrivelled’. In obstruction from other causes distension is common by comparison. However, if there is no disease in the gall bladder and the obstruction is due to a cancer of the ampulla, pancreas or bile duct, then the gall bladder may well be distended.

Management

It is essential to determine whether the jaundice is due to liver disease, disease within the duct such as sclerosing cholangitis or obstruction. Ultrasound scanning, liver function tests, liver biopsy if the ducts are not dilated, and MRI or ERCP will demarcate the nature of the obstruction.

The patient may be ill. Pus may be present within the biliary tree and liver abscesses may be developing. Full supportive measures are required with rehydration, attention to clotting, exclusion of diabetes and starting the appropriate broad-spectrum antibiotics. As soon as resuscitation has taken place, relief of the obstruction is essential. Endoscopic papillotomy is the preferred first technique with a sphincterotomy, removal of the stones using a Dormia basket (Fig. 54.42) or the placement of a stent if stone removal is not possible. If this technique fails, a percutaneous transhepatic cholangiogram can be performed to provide drainage and subsequent percutaneous choledochoscopy. Surgery, in the form of choledo­chotomy, is now rarely used for this situation as most patients can be managed by minimally invasive techniques (Fig. 54.43).

Choledochotomy

If a stone (or stones) is present in the common bile duct ,removal should have priority over cholecystectomy. Should the patient be unfit for cholecystectomy, or even cholecys­tostomy, the gall bladder should be removed on a future occasion (‘a living problem is better than a dead “cert”’ —Grey Turner). In particular, this may be the case in suppurative cholangitis. Recent evidence suggests that subse­quent cholecystectomy may not be necessary. After endoscopic removal of stones, only 10 per cent of patients will have subsequent problems with their gall bladder.

Supraduodenal choledochotomy

Most stones in the common bile duct can be removed by this route. If, as is often the case, a stone can be felt, an attempt is made to manoeuvre it into a position midway between the entrance of the cystic duct and the superior border of the duodenum. The stone is steadied between the finger and thumb. The duct is opened longitudinally directly on to the stone, enabling it to be removed by a malleable scoop or Desjardin’s gallstone forceps. The interior of the duct is then explored upwards and downwards with the scoop for further stones.

When the stone cannot be felt, or cannot be manipulated into the optimum position just described, 2 cm of the common bile duct is exposed, two stay sutures are placed in the duct and a longitudinal incision into the duct is made between them. Escaping bile is mopped up or removed by suction. Through this opening it may be possible to identify the stones and remove them with a scoop or forceps (Fig. 54.44). A balloon catheter, similar to that used for embolec­tomy, and irrigation of the ducts with saline are useful additional methods. Choledochoscopy may be employed to confirm that all calculi have been removed. Usually drainage of the common bile duct is carried out by means of a T-tube (Fig. 54.45); T-tubes should be made of latex or rubber and used only once — plastic tubes are hardened by the bile and are difficult to remove. Latex and rubber stimulate fibrinous adhesion of the omentum to liver and colon to form a safe track. There is very little reaction to a plastic tube and there­fore the risk of biliary peritonitis is greater. The transverse limb, shortened if necessary to about 5 cm long, is inserted in the duct which is closed snugly about the vertical limb, using fine catgut on an atraumatic needle. The long limb is brought out through a separate stab wound laterally, as this facilitates the Burhenne procedure should it subsequently be required for a retained stone. The bile draining from the tube is collected in a plastic bag by the side of the bed, its amount and character being noted. After 10 days the tube may be clamped for increasing periods, and the absence of pain and jaundice and the presence of bile in the stools indicate satisfactory flow into the duodenum. Sodium diatrizoate is injected down the tube to obtain a cholangiogram, and if there are no filling defects in a well-outlined duct, and the contrast enters the duodenum freely, the T-tube can be removed. Subsequent bile drainage is minimal and does not usually persist for more than 1 day.

Closure of the common duct without a T-tube

If this procedure is attempted, it is essential to provide drain­age placed in apposition to the common duct.

Transduodenal sphincterotomy

Transduodenal sphincterotomy is indicated when a stone is found to be impacted near the ampulla of Vater (Fig. 54.46) and it cannot be retrieved from above. Other indications are when the common bile duct is dilated and contains multiple stones and biliary sludge, and when the papilla is fibrosed and stenosed secondary to the passage of stones through it. Some surgeons prefer the method to supraduodenal choledochotomy to remove all duct stones. If the supraduodenal approach fails to clear the duct, it is preferable to place a large T-tube in the duct (14 or 16 Fr) and close the abdomen. Subsequently, the stone can be removed by the Burhenne procedure or endoscopically. The combination of a supra­duodenal approach with a transduodenal approach frequent­ly leads to complications.

The duodenum is opened in its second part between stay sutures and the region of the ampulla brought into the opening by traction using tissue forceps. Removal of the stone or stones requires division of the duodenal papilla and the sphincter. A grooved director is passed through the papillary opening and up into the bile duct where it must be palpated. The papilla and part of all the sphincter are now divided at 10 o’clock. If the bile-duct mucosa is sutured to that of the duodenum, the procedure is called a sphincteroplasty. Before sutures are placed in the papilla, it is essential to identify the pancreatic duct.

Choledochoduodenostomy

Choledochoduodenostomy is an alternative to transduodenal sphincterotomy when the common bile duct is dilated and contains multiple stones and sludge, particularly in elderly people (Fig. 54.47). The operation is contraindicated if the common duct is not 15 mm or more in diameter, or it is impossible to make a stoma of 2—3 cm. The convalescence is usually surprisingly placid. It is, indeed, a procedure which has commanded much support.