Seventeen patients underwent treatment for retained common bile duct stones. In 7 patients the stones were removed via a T-tube tract using steerable catheters while 5 patients underwent ERCP and sphincterotomy and 5 underwent surgical re-exploration. Considering morbidity, mortality, success rate and patients\u27 stay in the hospital, non-operative modalities should be the treatment of choice for retained common bile duct stones

Azami, R

Hameed, T

Hamid, Kamran

Jaffery, W

English

eCommons@AKU

eCommons@AKUDepartment of Surgery Department of SurgeryMay 1993Retained stones in the common bile duct: results ofmanagementKamran HamidAga Khan University, kamran.hameed@aku.eduR AzamiAga Khan University, rizwan.azami@aku.eduW JafferyAga Khan University, wasim.jaffery@aku.eduT HameedFollow this and additional works at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surgPart of the Surgery CommonsRecommended CitationHamid, K., Azami, R., Jaffery, W., Hameed, T. (1993). Retained stones in the common bile duct: results of management. Journal ofPakistan Medical Association, 43(5), 90-92.Available at: https://ecommons.aku.edu/pakistan_fhs_mc_surg_surg/735RETAINED STONES IN THE COMMON BILE DUCT:RESULTS OF MANAGEMENTPages with reference to book, From 90 To 92 Khalid Hameed, Rizwan Azami ( Departments of Surgery, The Aga Than University Hospital, Stadium Road, Karachi. ) Wasim Jaffery ( Departments of Medicine, The Aga Than University Hospital, Stadium Road, Karachi. ) Tariq Hameed ( Department of Radiology, The Aga Khan University Hospital, Stadium Road, Karachi. ) ABSTRACT Seventeen patients underwent treatment tar retained common bile duct stones. In 7 patients the stoneswere removed Via 0 1-tube tract using steerable catheters while 5 patients underwent ERCP andsphincterotomy and 5 underwent surgical re-exploration. Considering morbidity, mortality, success roteand patients’ stay in the hospital, non-operative modalities should be the treatment at choice forretained common bile duct stones (JPMA 43:90 , 1993).INTRODUCTION Despite routine per-operative cholangiography and choledocoscopy during bile duct exploration,retained stones in the common bile duct following cholecystectomy continues to be a problem. The in-cidence of retained stones is not uncommon and occurs in 4-10% of patients1-3. Retained stones arediscovered on post-operative T-tube cholangiograms or the patient may present with cholangitis andobstructive jaundice later. Small stones may pass spontaneously but some need active intervention.Many options are available and include surgical re-exploration4,5, ERCP and sphincterotomy6-9,extraction through the T-tube tract using steerable catheters10-12 or flexiblecholedoscope/nephroscope13, chemical dissolution14,15 and percutaneous or extracorporeallithotripsy16.PATIENTS AND METHOD At the Aga Khan University Hospital all patients undergoing cholecystectomy have operative cholan-giograms, if abnormal, the common bile duct is explored through a supra-duodenal choledochotomyand choledoscopy is done using a rigid scope. Stones are removed by saline irrigation under pressure,Desjardins forceps, Fogarty biliary balloon catheters, Dormia baskets or by the stone grabbing forcepsmounted on the rigid scope. The common bile duct is closed over a large size T-tube (14F or more). Apostoperative T-tube cholangiogram is performed on the seventh to tenth day. Non-operative modalitiesavailable for removal of retained stones at our hospital include extraction via the T-tube tract usingsteerable catheters and ERCP/sphincterotomy.RESULTS In a retrospective study of 422 cholecystectomies, the common bile duct was explored in 66 patients(15%), there were 10 (2.3%) negative CBD explorations, retained stones on postoperative T- tubecholangiogram were detected in 4 patients and 2 patients presented with obstructive jaundice. In these 2patients stones were missed on operative cholangiogram. The incidence of retained stones being 1.4%(6 patients). Overall 17 patients underwent treatment for retained stones (11 patients were outsidereferrals). Five patients were treated by surgical re-exploration, 7 patients had a T-tube in situ and thesewere treated by extraction via T-tube tract and 5 were treated by ERCP/sphincterotomy. Variousmodalities of treatment have been compared with regard to cost, hospital stay, morbidity, mortality andsuccess, as shown in the Table.DISCUSSION Retained stones in the common bile duct can be removed if the T- tube is insitu, by saline orheparinized saline flushed down the T-tube14. This method is indicated if the stones are small and distalto the T-tube and the sphincter of Oddi is relaxed with glycerol trinitrate17 or glucagon. The methodmay be effective in 50% of the selected patients14. Stones can also be dissolved using agents such asmono-octanion or methyl tertiary butyI15. This chemical dissolution therapy has given variable results.Extraction of stones via the T-tube tract using steerable catheters is claimed to be the procedure ofchoice in a selected group of patients who have a T-tube in10,11. This procedure is done as a day case inthe radiology department after the T- tube has been in place for 4 weeks or more and the tract has‘matured’. No fasting or premedication are necessary. It is recommended that a size of 14F or a largerT-tube be used at surgery, as it makes subsequent extraction easier due to the large diameter of thetract12. The overall success rate of this procedure is reported to be 95%; no mortality was reported in aseries of 661 patients12, morbidity amounted to 5%. ERCP/sphincterotomy is the other modality whichis becoming the treatment of choice for removing retained CBD stones7,8,18. Safrany9 reported amorbidity of 6 to 8% and mortality of 1 to 2% in a large series. Surgical re-exploration has beenreported to carry a mortality of about 2 to 3%4,19. Mortality and morbidity increase with age and thepoor general health of patients, mainly in the form of sepsis and retained stones5. Various options areavailable to treat patients with retained common bile duct stones. Management of an individual patientdepends upon the• expertise and facilities available, the age and general health of the patient, size ofretained stones and whether a T-tube is in place. In a selected group of patients, extraction via the T-tube tract is a safe and cost-effective method. ERCP/sphincterotomy is also a valuable method oftreatment, however, it should be avoided in patients who have had recent surgery and aT-tube is in situ.Surgical re-exploration should be avoided if these non-operative modalities are available as it has ahigher morbidity and mortality, however, if the stones are large or when complications arise as a resultof ERCP/sphincterotomy, it may become necessary. At Aga Khan University Hospital patients withretained common bile duct stones have been managed mainly by ERCP/sphincterotomy and extractionvia the T-tube tract, surgical re-exploration has been done in special circumstances only.REFERENCES 1. Hicken, N.F., and McAllister, A.J. Operative cholangiography asan aid in reducing the incidence ofoverlooked” common bile duct stones. Surgery, 1964;55:753-8.2. Bergdahl, L. and Holmund, D.E. Retained bile duct stones. Acta chir. Scand., 1976;142:145-9.3. Farha, G.L. and Pearson, ltN.Tranacyaticductoperativecholangiography. Am.J.Surg., 1976;131:228-30.4. Smith, H.W.,Engel, c.,Averbrooks, B. and Longmire, W.P.Jr. Problemsofretained and recurrent CBDstones 5urgety, 1969;66:291-98.5. Sheridan, W.G., Williams, H.O. and Lewis, M.H. Morbidity and mortality of common bile ductexploration. Br.J.Surg., 1978;74:1095-9.6. O\'Doherty, D.P., Neoptolemos, J.P., Carr-locke, DL. Endoacopic aphincterotomy for retained CBI)stones in patients with T. tube in aitu in the early poatoperative period. Br.). Surg. 1986;73:454-6.7. Lambert, ME., Martin, D.F. and Tweddle, D.E.F. Endoacopic removal of retained atones afterbiliarysurgery. Br.). Surg., 1988;75:896-8.8. May, G.E. and Shaffer, E.H. Should endoscopic sphincterotomy replace cholecystec tomy for thetreatment of higher risk patients with gall stone pancreatitia? (editorial). 1dm. GastroenteroL,1991;13:125-&9. Safrany, L. Endoacopic treatment of biliary-tract diaeaae. Lancet, 1978;2:983-8.10. Burhenne, Hi. Non-operative retained biliary tract stone extraction. A new roentgenologictecbnique. AJR., 1973;117:388- 99.11. Burhenne, Hi. Non-operative inatrumentextraction ofretained bileductatonea. World 3. Surg.,1978;2:439-45.12. Burhenne, Hi. Percutaneous extraction of retained bilisty tract stones; 661 patients. AJR.,1980;134:889-98.13. Mathurak, SAC, Pardanani, D.S., Deshmukh, H.L. etal. Endoacopic removal ofretained bile ductcalculi via T-tube tract Indian). Gastroenterol., 1990;9:123-5.14. Motson, ftW. Dissolution ofcommon bile ductstonea. Br.J.Surg., 1981;6&203-8.15. Kaye, G.L., Summerlield, IA. and McIntyre, N. Methyl tert butyl ether dissolution therapyforcommon bile duct stones.J. HepatoL, 1990;10:337-40.16. Siegel, J.H., Bon-Zui, J.S.and Pullano, WE. Mechanical lithotripsyof common bile duct stone.Gastrointest-Endoec., 1990;36:351-6.17. Staritz, M., Poralla, T., Ewe, K. and Meyer Zum Buschenfelde, K.H. Effect of glyceryltrinitrate onthe sphincter of oddi motility and baseline pressure. Gut, 1985;26:194-7.18. Taodon, R.K., Nijhawsn, S. and Arors Aera, A. Management of retained common bitt duct stones inpatients with T-tube in situ: role of cndoscopic aphincterotomy. Am.J.Gastroenterol., 1990;85:1126-31.19. McSherry, C.K. and Glenn, F. The incidence and causes of death following surgery for non-malignant biliary tract disease. Ann. Surg., 1980;191:271-5.

Retained stones in the common bile duct: results of management

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Retained stones in the common bile duct: results of management

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