Dec 10, 1972 - biliary calculi following cholecystectomy and exploration of the common bile ductin the ... duct, but the patient's condition was so poor at this stage that ... attacks of right upper quadrant pain, and low grade post washout fevers.
Retained Biliary Calculi: Removal by
a
Simple Non-operative Technique
P. B. CATT, D. F. HOGG, G. J. A. CLUNIE, 1. R. HARDIE
Ten patients with retained biliary calculi demonstrated by postoperative T-tube cholangiography were managed by a simple nonoperative washout technique. The bile was cultured routinely before each group of washouts, since fever was a common sequel in the presence of infected bile. After a parenteral dose of propantheline bromide, the biliary tree was flushed through the T-tube with 1 litre of normal saline containing 40 ml of lignocaine. Progress was followed by T-tube cholangiography, and the criterion of success was a cholangiogram showing adequate filling of the biliary tree, absence of filling defects, and free flow of contrast medium into the doudenum. The technique was successful in six of the ten patients. There was no mortality and no significant morbidity.
T HE ROUTINE USE of intraoperative cholangiography has reduced the incidence of retained biliary calculi following cholecystectomy and bile duct exploration, but calculi are still demonstrated in a significant number of cases by postoperative cholangiography.l 9,12,14 Removal of the draining T-tube in the hope that the stones will pass spontaneously or cause no further trouble has proved unsatisfactory, since 8 out of 10 patients develop symptoms or complications requiring re-exploration.3 Such reoperation is associated with a significant mortality and morbidity, and the chances of finding and removing residual calculi fall progressively with the second and each subsequent exploration.5'13 Various nonoperative techniques for dealing with retained calculi have been proposed, including- chemical dissolution, flushing with a variety of solutions, and extraction with instruments or catheters passed down the T-tube track,2'4'6-8,10,11,14 but none of these methods has found wide acceptance. In 1967, Hivet and Richarme4 Submitted for publication November 21, 1973. 247
From the Department of Surgery, University of Queensland, Princess Alexandra Hospital, Brisbane, Queensland, Australia
reported five cases in which calculi were successfully washed out of the ducts by a simple saline flush. This report describes a modification of this technique, and its application in ten patients with retained bile duct stones.
Materials and Methods In the three-year period from January 1970 to December 1972, nine partients were found to have retained biliary calculi following cholecystectomy and exploration of the common bile duct in the University Surgical Unit at the Princess Alexandra Hospital, Brisbane. A tenth patients was referred from another unit in the same hos-
pital. In each patient, aerobic and anaerobic cultures of the bile were undertaken at 7 days, and routine T-tube cholangiography was performed at intervals of from 9 to 12 days after the primary procedure. Following the radiological demonstration of residual calculi, propantheline bromide was administered intramuscularly 30 minutes before flushing of the bile ducts with 1 litre of sterile 0.9% saline at room temperature containing 40m1 of 1% lignocaine, suspended 1 m above the mid axillary line. The saline bottle was connected to the T-tube through a standard intravenous administration set, and the infusion was started slowly, since all patients experienced initial discomfort. As this subsided, the solution was allowed to flow as rapidly as possible. The patient's position was altered to direct the stream into all parts of the biliary tree in an attempt to dislodge the calculi. Three
Ann. Surg. * August 1974 CATT, HOGG, CLUNIE AND HARDIE washouts were given at daily intervals, and the T-tube attacks of right upper quadrant pain, and low grade post washout fevers. On a post washout cholangiogram, the smaller (10 x 5mm) was clamped after each procedure. If the patient deof the two calculi could no longer be demonstrated, but the the tube was and veloped pyrexia, immediately released, larger (14 X 10mm) calculus was still present. Before any further free drainage of the biliary system re-established. Results washouts could be performed, the patient accidentally stepped on were assessed by further T-tube cholangiography prior the T-tube while getting out of bed and dislodged it. Following to remoial of the T-tube. Success was indicated by a a further attack of cholangitis re-exploration of the common bile duct was performed. Six months after the initial episode the papost-washout cholangiogram showing adequate filling of tient was readmitted with a locally invasive cystadenocarcinoma the biliary tree, no filling defects, and free flow of the of the ovary, which was treated by panhysterectomy and removal contrast medium into the duodenum. of an involved segment of pelvic colon. At present she is free of
248
Case
Reports
Case 1. D.T., a 65-year-old woman, was admitted on April 22, 1970 with obstructive jaundice, ascending cholangitis, and an E.coli septicemia. Cholecystectomy had been carried out 10 years
previously in another hospital. The patient did
to conservative
treatment, and the bile ducts
not
respond
were explored on 1970. Soft stones and mud were removed from duct system. a at least two further calculi in the common hepatic the condition was so poor at this stage that was not The patient made a good and on the 12th postoperative day, a further T-tube
April 24, biliary a dilated Completion cholangiography through T-tube suggested duct, but patient's further exploration performed. recovery, cholangiogram confirmed the presence of two residual calculi. Bile culture showed a growth of mixed enteric organisms. Washouts were carried out daily on three occasions from the 20th day, each washout being associated with mild initial discomfort, acute
FIG. 1. Ten-daycholangiogramin Case 4 showing a 7 x 7 calculus at the lower end of the common bile duct.
mm
biliary symptoms, although there is evidence of local extension of the carcinoma. Case 2. L.C., a 58-year-old man, underwent cholecystectomy on May 5, 1970 following an acute attack of cholecystititis. The gall bladder contained multiple faceted calculi and an operative cholangiogram demonstrated a dilated duct system. No stones were found on exploration, and no completion cholangiogram was performed. Bile culture in the postoperative period was sterile. A 10-day T-tube cholangiogram demonstrated a solitary calculus 9 X 7 mm in size at the lower end of the common bile duct. Three washouts were performed, each accompanied by some initial discomfort, but no colic and no post washout fever. Repeat cholangiogram showed no change, and the calculus was removed at a second operation. The patient remains well with no further symptoms. Case 3. C.F., a 20-year-old woman, had suffered from repeated attacks of biliary colic prior to cholecystectomy on April 5, 1971. The gall bladder contained multiple small calculi, and an operative cholangiogram demonstrated multiple calculi in the common mile duct and common hepatic duct. Twenty-five small calculi were removed on exploration of the duct system. The completion cholangiogram was of poor quality, but was interpreted as showing no abnormality. The 10-day cholangiogram demonstrated at least 11 small defects scattered throughout the bilitary tree. These were initially interpreted as air bubbles, but remained constant on two further cholangiograms. The largest of the defects was 5 x 5 mm, and the smallest 2 x 2 mm. Bile culture showed a growth of mixed enteric organisms. Over the next 53 days, 13 washouts progressively cleared these defects, now definitely considered to be calculi. The patient experienced initial discomfort and recurring attacks of right upper quadrant pain, high fever, rigors and diffuse myalgia with each washout. Each febrile episode subsided rapidly on unclamping the draining T-tube. No antibiotic therapy was utilised. The final T-tube cholangiogram was interpreted as showing no evidence of residual calculi, and the T-tube was removed. Two small stones 2 X 2 mm in size were found in the short limb of the T-tube, and in retrospect, these calculi can be seen on the final cholangiogram. The patient has had no further biliary symptoms. Case 4. A.A., a 47-year-old woman, had suffered from recurrent episodes of biliary colic and was submitted to cholecystectomy on September 13, 1971. The gall bladder contained multiple small calculi, and an operative cholangiogram demonstrated multiple calculi in the bile ducts. On exploration, 14 small stones were found and removed from the biliary tree. No completion cholangiogram was performed. Bile cultures demonstrated a growth of mixed enteric organisms. A 10-day cholangiogram (Fig. 1) showed a 7 x 7 mnn calculus at the lower end of the common bile duct. This calculus was successfully cleared after a series of three washouts (Fig. 2). With each washout, the patient developed initial discomfort, several episodes of acute right upper quadrant pain, but no post washout fever. The patient has had no recurrence of biliary symptoms. Case 5. A.R., a 74-year-old woman, presented on September 16, 1971 with obstructive jaundice and mild cholangitis. Cholecystec-
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RETAINED BILIARY CALCULI
tomy and choledocolithotomy had been carried out at another hospital 7 years previously. The patient was treated conservatively and a later intravenous cholangiogram showed two large calculi at the lower end of the common bile duct. Exploration was carried out on October 4, 1971, one large calculus being removed while a second large soft calculus fragmented during removal. Completion cholangiogram was of poor quality but was accepted as showing no abnormality. Bile cultures showed a growth of mixed enteric organisms. A 10-day T-tube cholangiogram demonstrated multiple defects varying in size from 8 x 8 mm to 2 X 2 mm, which were presumed to be due to fragments of the second large calculus, and which were still present on a 12-day cholangiogram. Four washouts were given at daily intervals from the 12th day, each washout being accompanied by initial discomfort, acute exacerbations of right upper quadrant pain, and mild post washout fever. The final cholangiogram showed no evidence of residual calculus. The patient has had no recurrence of biliary symptoms. Case 6. E.R., an 82-year-old woman, was admitted on May 28, 1972 with acute cholecystitis. After 24 hours of conservative management, increase in local and systemic signs lead to laparotomy, when an acutely inflammed gall bladder containing multiple faceted calculi, and with a perforation of the fundus was found. A large calculus could be palpated in the common bile duct and its presence was confirmed on the operative cholangiogram. Cholecystectomy was carried out, and a single large calculus was removed from the common bile duct. The completion cholangiogram was of poor quality, but was not repeated in view of the patient's poor general condition at this stage of the operation. Bile cultures demonstrated a growth of mixed enteric organisms. A 10-day T-tube cholangiogram demonstrated a 10 X 5 mm filling defect. A single washout was carried out under image intensifier control on the 17th postoperative day. The calculus was visualised initially at the lower end of the common bile duct, but was no longer visible at the end of the procedure. This washout was accompanied by mild initial discomfort, severe acute pain in the right hypochondrium, and a mild post washout fever. A T-tube cholangiogram 2 days later showed no evidence of residual calculus. The patient has had no recurrence of biliary symptoms. Case 7. N.W., a 79-year-old woman, was admitted with a history of recurrent episodes of biliary colic. At operation on September 24, 1972 the gall bladder was found to contain multiple facetted stones and was removed. The duct system was moderately dilated and several calculi were seen at the lower end of the common bile duct on the operative cholangiogram. Nine calculi were removed during exploration of the duct system. Completion cholangiogram showed no evidence of passage of contrast medium into the duodenum, and there appeared to be some deformity of the lower end of the common bile duct. Transduodenal sphincterotomy and re-exploration of the duct were therefore performed, but no further calculi were found. No final completion cholangiogram was performed. Bile cultures showed a growth of mixed enteric organisms. A 12-day cholangiogram demonstrated a 10 X 3 mm calculus at the lower end of the common bile duct. A single washout was carried out on 17th postoperative day, and was accompanied by initial discomfort, multiple attacks of acute right upper quadrant pain, and mild post washout fever. A final cholangiogram showed no evidence of residual calculus. The patient has had no recurrence of biliary symptoms. Case 8. H.C., an 80-year-old won l, had suffered many attacks of cholecystitis associated with jaundice in the six months prior to cholecystectomy on December 19, 1972. At operation, the gall bladder contained multiple calculi, and two stones were palpable in the common bile duct. Six small stones were removed on exploration of the duct system, and the completion cholangiogram was interpreted as showing no abnormality. Bile culture showed a growth of mixed enteric organisms. The 10-day cholangiogram
249
FIG. 2. Cholangiogram in Case 4 taken after a series of 3 washouts demonstrating successful clearing of the calculus.
showed several small defects which were interpreted as air bubbles, but one defect, measuring 8 X 6 mm, was still apparent at the junction of the right and left hepatic ducts on a further cholangiogram. A washout was performed under image intensifier control on the 20th postoperative day. The calculus was visualised initially in the left hepatic duct and subsequently below the T-tube at the lower end of the common bile duct. This washout was accompanied by mild initial discomfort and severe acute pain radiating from the epigastrium to the back but no post washout fever. Further washouts on each of the next 2 days were accompanied by initial discomfort and a low grade post washout fever, severe acute pain occurring once only in the first of these two washouts. A final T-tube cholangiogram was interpreted as showing no residual calculi, and the T-tube was removed. However, the patient was readmitted 1 veek later with biliary colic and jaundice, and a later intravenous cholangiogram showed a filling defect at the lower end of a dilated common bile duct. Review of the T-tube cholangiogram demonstrated that this stone had been apparent in the final x-rays, which were misinterpreted. A 8 X 6 mm calculus was removed at re-exploration on February 13, 1973, following which the patient has ha(l no further biliary symptoms. Case 9. P.F., a 21-year-old man, was admitted on December 10, 1972 with obstructive jaundice and cholangitis which failed to settle with conservative management. A percutaneous transhepatic cholangiogram on December 21, 1972 showed complete obstruction of the lower end of the common bile duct, and cholecystectomy with exploration of the bile ducts was performed on the same day. The gall bladder was edematous and contained several pigment stones. Many soft pigment stones were removed from
250C~ the common bile
Ann. Surg. * August 1974 CATT, HOGG, CLUNIE AND HARDIE duct, but completion cholangiogram was not TABLE 2. Calculus Size, Number and Position, as Determined from
the Cholangiographic Films performed because of peroperative hypotension. Operative bile culture showed a growth of Pseudomonas aeruginosa. Largest The 11-day cholangiogram and a repeat examiination on day Calculus 12 showed many filling defects with the appearances of air bubbles, Case Number Position (m.m.) but a further cholangiogram on day 21 showed persistence of a 10 14 2 1 C.B.D. X single defect 5 X 4 mm in diameter, apparently impacted at the 2 9 X 7.5 1 C.B.D. lower end of the common bile duct. A washout performed under 3 5 X 5 C.B.D. C.H.D. multiple image intensifier control on that day produced vigorous perstalsis at L.H.D. R.H.D. the lower end of the common bile duct which was associated with 4 7 X 7 1 C.B.D. severe acute pain in the right hypochondrium, but no contrast me5 8 X 8 C.B.D. C.H.D. multiple dium passed into the duodenum. There was a mild post washout 6 10 X 5 1 C.B.D. fever. Four further washouts carried out over the next 21 days 7 10 X 3 1 C.B.D. were accompanied only by mild initial discomfort, with no severe 8 1 8X6 L.H.D. pain or fever. A T-tube cholangiogram 4 days after the last wash9 5 X4 1 C.B.D. 10 4 X4 1 C.B.D. out showed no evidence of residual calculus. The patient has had no recurrence of biliary symptoms. C.B.D. Common Bile Duct Case 10. J.G., a 71-year-old woman, had suffered from reL.H.D. Left Hepatic Duct current episodes of biliary colic for 3 years prior to cholecystecR.H.D. Right Hepatic Duct tomy on February 6, 1973. The gall bladder contained numerous C.H.D. Common Hepatic Duct calculi, and an operative cholangiogram demonstrated several small calculi at the lower end of the common bile duct. On exploration The number of calculi and their size were estimated seven smal stones 4 mm in diameter were removed from the biliary tree. Completion cholangiogram was accepted as showing no ab- from the cholangiographic films (Table 2). In the unsucnormality. Bile cultures showed a growth of mixed enteric or- cessful group, the largest stone measured 14 x 10 mm, ganisms. A 9-day cholangiogram was not of diagnostic quality, and and the smallest 4.0 x 4.0 mm. The largest stone successthe examination was therefore repeated on the 20th postoperative day, demonstrating a 4 x 4 mm calculus in the common bile duct fully washed out measured 10 x 5 mm, and the smallest just proximal to the upper limb of the T-tube. Seven washouts 2 x 2 mm. In two of the successful group, calculi were were performed over the next 30 days, each accompanied by slight present in the common hepatic duct and its radicals initial discomfort but no colic, with low grade post-washout fever proximal to the T-tube, in addition to those in the comfollowing only the first. This fever subsided rapidly on unclamp- mon bile duct. The largest of these proximal calculi measing the T-tube and administration of appropriate antibiotics. Further cholangiograms were performed after the second, fifth, and ured 3 x 3 mm and the smallest 2 x 2 mm. However, a seventh washouts and each showed no change in the position of larger proximal stone, 4 x 4 mm in size, was not washed the calculus, which was removed at a second operation. The pa- out. tient remains well, with no further symptoms. All patients experienced initial discomfort, which was controlled by slowing the rate of flow. Eight also easily Review of Results of episodes of sharp pain in the upper abdocomplained The results obtained in this group of ten patients are men with back lasting from a few seconds to summ.arised in Table 1. In three patients, the procedure several minutes. radiation In seven of these eight patients, stones was unsuccesful, and in one, misinterpretation of the were washed out, although in one patient cholangiogram led to retention of a calculus. In the re- (Casesuccessfully further a calculus remained at the enforced 1), maining six patients, the stones were cleared by the flush- termination of washout therapy. ing procedure. Two patients responded to a single washNine of the ten showed a growth of mixed out, one was successful after three, one after four, one enteric organisms inpatients the bile (Table 3), and eight of
after five, and in the remaining case multiple small calculi required 13 flushing procedures over a 53-day period. TABLE 1. Number of Washouts and Result
Case 1
2 3 4 5 6
7 8 9 10
No. of Washouts 3
3 13 3 4 1 1 3 4
7
Result Unsuccessful (T-tube accidently removed) Unsuccessful Successful Successful Successful Successful Successful Unsuccessful (X-ray misinterpreted) Successful Unsuccessful
these developed pyrexia following the washouts. One patient developed a high fever, rigors and diffuse myalgia at the time of each procedure, but in the remaining seven, fevers were mild, and the patients were unaware of any upset. The patient with sterile bile developed no fever. There were no residual effects, and the six patients
with successful washouts have shown no evidence of residual stones at inte-r^tls of 6 months to 3 years since the
procedure. Discussion The technique of bile duct flushing described in this report was successful in clearing residual calculi from the bile ducts in six of the ten cases treated. The morbidity associated with the procedure was of minor degree in
RETAINED BILIARY CALCULI
Vol. 180 * No. 2
or-,
all but one case. The initial discomfort experienced as treated by the same technique with clinical relief of obthe perfusion was started was presumably due to disten- struction and satisfactory final cholangiography. It is not tion of the biliary tree, and the acute exacerbations of clear whether the cause of obstruction in these three papain were considered to be caused by temporary obstruc- tients was simple sphincter spasm, fragments of blood tion of the ampulla by a calculus. Although such pain clot or small residual calculi, but the washouts were folmay indicate passage of a stone, clearly further T-tube lowed by clinical and radiological relief of obstruction. The results obtained in this small series suggest that cholangiography must be utilised in order to determine the technique of flushing is a safe and simple one, and the success or failure of the procedure. The fever seen in eight patients was presumed to be that it has a significant place in the management of defidue to transient bacteremia from cholangio-venous reflux. nite retained biliary calculi, or where some doubt exists It is significant that pyrexia was not seen in the single as to the presence of residual calculi. It is unlikely that patient with sterile bile. We believe that such cholangio- it will be successful in every instance, as this series shows, venous reflux represents a potential source of more seri- but we feel that it should be used routinely before reous morbidity and perhaps even mortality, and for this sorting to the more prolonged technique of chemical soreason have always cultured the bile before each group lution,14 or surgical re-exploration. of washouts. Although appropriate prophylactic or therapeutic antibiotics were not used routinely in this series, Acknowledgments there may be an argument for their administration, parWe wish to thank our colleagues for referral of patients, ticularly in the elderly or the ill. Dr. E. R. Jay of the Department of Radiology, Princess Two of the four failures came early in our experience, Alexandra Hospital for the investigations, one following accidental removal of the T-tube, and the and Professor W. Burnett for radiological his advice and encourageother after what we would now consider an inadequate ment. trial of the method. The presence of the T-tube did not prevent the washout of multiple proximal stones up to 3 References mm in diameter in two patients, but a 4mm diameter stone in a third patient was not cleared. We believe the 1. Burnett, W. and Bolton, P. M.: Operative Cholangiography in the Surgery of Gall Stones: Implementation of a Policy retention of the T-tube offers advantages in maintenance Decision in a Consecutive Series of 327 Patients. Aust. of drainage when compared with the rather similar flushN.Z. J. Surg., 42:14, 1972. ing technique described by Lamis, Letton and Wilson,' 2. Fennessy, J. J. and Kwang-Duck You: A Method for the Exwhere the T-tube is removed after a well-defined track pulsion of Stones Retained in the Common Bile Duct. Am. J. Roetgenol., 110:256, 1970. has been established, and a coud6 tipped rubber catheter A. J. and Call, D. W.: Residual inserted. However, this technique may be of greater value 3. Hicken, N. F., McAllister, Choledochal Stones. Arch. Surg., 68:643, 1954. with large proximal stones. The fourth failure was due to M. and Richarme, J.: Lithiase Restante du Choledoque. a misinterpretation of the T-tube cholangiogram, and 4. Hivet, Ann. Chir., 20:1077, 1966. demonstrates the importance of careful review of the 5. Kune, G. A.: The Elusive Common Bile Duct Stone. Med. J. radiographic appearances before final removal of the Aust., 1:254, 1966.
T-tube. In the same three-year period, a further three patients in the Unit in whom there was definite clinical but equivocal radiological evidence of biliary obstruction following exploration of the common bile duct have been TABLE 3. Relationship of Bile Infection and Post-washout Fever
Case 1 2 3 4 5 6
7 8 9 10
Infected Bile yes no yes yes yes
yes yes yes yes yes 9
Fever yes no yes (rigors) no yes yes yes yes yes yes 8
6. Lamis, P. A., Letton, A. H. and Wilson, J. P.: Retained Common Duct Stones: A New Nonoperative Technique for Treatment. Surgery, 66:291, 1969. 7. McBumey, R. P. and Gardner, H. C.: Non-surgical Removal of Retained Common Duct Stones. Ann. Surg., 173:298, 1971. 8. Magarey, C. J.: Non-surgical Removal of Retained Biliary Calculi. Lancet, 1:1044, 1971. 9. Mullen, J. L., Rosato, F. E., Rosate, E. F., Miller, W. T. and Sullivan, M.: The Diagnosis of Choledocolithiasis. Surg. Gynecol. Obstet., 133.774, 1971. 10. Mazzariello, R.: Removal of Residual Biliary Tract Calculi Without Reoperation. Surgery, 67:566, 1970. 11. Sasson, L.: Dissolution and Flushing Technics for Removal of Retained Common Duct Stones. Am. J. Gastroenterol., 51:394, 1969. 12. Schulenburg, C. A. R.: Operative Cholangiography. London, Butterworths, 208, 1966. 13. Smith, S. W., Engel, C., Averbrook, B., Longmire, Jr., W. P.: Problems of Retained and Recurrent Common Bile Duct Stones. JAMA, 164:231, 1957. 14. Way, L. W., Admirand, W. H. and Dunphy, J. E.: Management of Choledocholithiasis. Ann. Surg., 176:A347, 1972.
