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
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).