Choledocholithiasis after cholecystectomy Choletithiasis

WILLIAM G. ANDERSON, D.O.

Detroit, Michigan

In spite of thorough exploration of thecommon duct at primary surgery for diseaseof the biliary tract, and despite everyeffort to remove stones when they arediagnosed, stones occasionally are leftbehind. They may be overlooked or may belodged in the intrahepatic duct or adiverticulum where they are inaccessible.Not all retained stones produce symptoms,and many will not be detected. When theyare discovered, it may not be necessaryto operate immediately. If they are smalland obstruction is incomplete, withoutserious complications, watchful waitingmay be advisable, and various mechanicaland physiologic agents may be used forbiliary flush.

Although some surgeons claim that they neverleave stones in the biliary ducts at the time ofcholecystectomy, any surgeon who does a largenumber of explorations of the common duct, nomatter how careful and painstaking his tech-nique, ultimately will encounter a. stone re-tained in the common duct when the cholangio-gram is made just prior to anticipated removalof a previously positioned T-tube.

Many methods have been employed to re-move such retained stones. Among them is the"biliary flush" described by Best,' in whichhydrocholeretic agents, sphincter relaxants,and T-tube irrigations with various potionsand unctions including ether and chloroformand warm paraffin or olive oil are used. Whenother measures fail, reoperation may be neces-sary.

It is the purpose of this paper to review oldand new techniques employed in the treatmentof this common problem and their results.Some adjunctive measures which may be ofvalue in removing retained ductal stones alsowill be considered.

Incidence and originStones rarely are formed in the biliary tractafter cholecystectomy unless the conditionsthat predispose to cholelithiasis and choledo-cholithiasis persist. These are infection, partialobstruction leading to stasis, as in stricture oranother stenosing mechanism that impairs thebile flow, and, rarely, intestinal infestations.Usually the stones found in the ductal systemafter cholecystectomy were present at the timeof the initial operation. Such stones may haveoriginated in the gallbladder and been forciblyexpelled from the gallbladder during normalcontractions, or surgical manipulation may beresponsible for migration of stones into thebile ducts. Stones that erode through the wallof the gallbladder rarely enter the ductal sys-tem; such stones generally find their way intothe small bowel, with resulting gallstone ileus.Berk and Kaplan2 have stated that choledo-cholithiasis occurs in from 8 to 25 percent ofthe general population, the higher incidencebeing among patients with cholecystolithiasis.The incidence of both conditions increases withadvancing age. There is a preponderance offemale over male patients in the younger agegroup, but the incidence in the two sexes isapproximately the same after the eighth dec-ade of life. In a review of several reports, Berk3found that stones were present in the bile ductin approximately 9 percent of patients whowere operated on for acute cholecystitis and 13percent of those operated on for chronic chole-cystitis. The incidence of choledocholithiasisamong patients who have undergone chole-

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cystectomy and have not become. symptomaticis difficult to ascertain. However, Glenn's' sur-vey of patients on whom cholecystectomy with-out choledochotomy was done showed that 4percent required subsequent choledocholithoto-my. A similar survey by Smith and associates,showed an incidence of 0.8 percent.

In addition to the gallbladder, another pos-sible source of stones in the common duct aftercholecystectomy apparently is the intrahepaticductal system. Stones may well migrate fromproximal sites in the biliary tree to find theirway into the common hepatic and common bileducts and to be productive of the distressingsymptoms associated therewith.

Ferris and Sterling6 reported that at theMayo Clinic 95 percent of the patients sub-jected to cholecystectomy had cholecystolithia-sis. Of these patients, 20 percent underwentcommon duct exploration and stones werefound in about 45 percent. These figures sug-gest a high degree of correlation betweenthe presence of cholecystolithiasis and of chole-docholithiasis and warrant the conclusion thatmany patients are inadequately treated andare liable to have symptoms due to stones aftercholecystectomy.

Pathologic findings

The stones present in the bile ducts aftercholecystectomy are of the same chemicalmakeup as those found in the gallbladder andvary from' the more common cholesterol stonesto the rare calculi surrounding foreign bodiessuch as worms. Stones may contain bile pig-ments or cholesterol or combinations of thesewith fatty acids, triglycerides, polysaccharides,and protein. Stones originating in the gall-bladder often have the characteristics of typ-ical gallbladder cholesterol stones, while stonesthat arise from the bile ducts tend to have alarger proportion of bilirubin.

Infection and inflammation invite stone for-mation, and unfortunately there is a reciprocalrelation, in that stone formation invites in-flammation and infection. The inflammatorychange may be relatively mild and chronic orsevere and acute with extension to the adja-cent tissues and liver. Abscess formation isnot infrequent. Obstruction of the bile flow

may be partial or incomplete, depending onthe size and location 'of the stone and theassociated inflammatory change.

Signs and symptomsPuestow7 stated that sudden pain in the rightupper quadrant after cholecystectomy is sug-gestive of choledocholithiasis if it increasesin severity and radiates through the back andthe angle of the right scapula. The symptomsof choledocholithiasis are not unlike those ofcholecystolithiasis, but they tend to be moresevere. Similar symptoms may have been pres-ent prior to cholecystectomy, and in the ab-sence of other demonstrable disease the per-sistence of such symptoms should certainlylead one to suspect the presence of residualstones in the ductal system. Chills, fever, andjaundice associated with the pain describedshould heighten the suspicion of residualstones in the ducts.

The pain is generally colicky, severe, andof long duration and may be difficult to relieve.It is associated with obstruction of the ductand is relatively sudden and progresses rap-idly.

Chills and fever are not consistently ob-served and may be related to the presence ofinfection and other inflammatory change.Various studies have shown that these symp-toms are present in from 4.2 to 40.2 percentof cases.2

Jaundice, when present, is a most reliablesign if careful differential diagnosis was donebefore operation. It usually appears soon aftersevere colic and may disappear entirely aftersubsidence of pain. The absence of jaundicedoes not rule out choledocholithiasis, however.Its presence may depend on the extent ofobstruction of the ductal system produced bythe retained stones. Relatively large residualstones that are free in the common duct mayproduce no symptoms.

Stones may cause intermittent obstruction,with relief of the obstructing mechanism be-fore clinical jaundice appears.

A less frequent but distressing symptomsuggestive of choledocholithiasis after cholecy-stectomy is peritonitis secondary to a bile leakfrom the cystic duct stump, or, after chol-

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edochostomy without placement of a T-tube,from the common duct. The diagnosis occa-sionally may be made by noting the presenceof profuse bile drainage from the operativesite.

Nausea, vomiting, and dyspeptic symptomssuch as fullness, belching, and the presence ofgas generally are not specifically related to thepresence of choledocholithiasis. However, suchsymptoms do occur and should increase thephysician's suspicion when they are presentafter cholecystectomy.

None of the aforementioned symptoms maybe present, however. The existence of the so-called silent stone picture makes accurate de-termination of the incidence of choledochol-ithiasis after cholecystectomy impossible.

DiagnosisThe history and physical examination con-tribute greatly to the clinician's suspicion, butat best they can offer only presumptive evi-dence of the presence of choledocholithiasis.Biliary colic, jaundice, chills, and fever aftercholecystectomy for cholecystolithiasis strong-ly suggest the diagnosis.

When a T-tube is present, T-tube cholangi-ography may be diagnostic. Intravenous chol-angiography may be employed if the patientis not jaundiced or if jaundice is intermittentand the serum bilirubin level is sufficientlylow to indicate that liver function is adequatefor excretion of the radiopaque medium. Per-cutaneous transhepatic cholangiography maybe required for definitive diagnosis in the pa-tient who is jaundiced and does not have aT-tube in the duct.

Certain laboratory data are useful. A com-plete blood count and blood chemical studies,especially determinations of bilirubin alkalinephosphatase, glutamic oxaloacetic transamin-ase, and glutamic pyruvic transaminase in theserum may suggest the presence of diseaseof the biliary tract or liver. The urine andfeces may be examined for urobilinogen. Du-odenal drainage may be of value in the absenceof bile in the gastrointestinal tract. Often aplain, flat roentgenogram of the abdomen maydemonstrate a retained ductal stone.

TreatmentPrimary surgeryIf choledocholithiasis after cholecystectomy isviewed as a sign of inadequate surgery, it maybe concluded that adequate surgery may elim-inate the problem.

However, it should be re-emphasized thatany surgeon who performs cholecystectomyfor cholecystolithiasis with careful and pains-taking exploration of the common duct will onoccasion overlook a stone in the common,hepatic, or intrahepatic duct which may latercause irritation or obstruction. Operative chol-angiography, first described by Mirizzi s in1937, has served greatly to improve the dis-closure of stones within the ductal system atthe time of the initial operation.

The indications for exploration of the com-mon duct are as follows:

(1) The presence of multiple small stonesin the gallbladder;

(2) a history of or the presence of jaundiceor acholic stools, intermittent or per-sistent;

(3) dilatation or thickening of the commonbile duct;

(4) dilatation of the cystic duct;(5) presence of palpable mass within the

bile duct;(6) inflammation of the common duct with

gallbladder disease;(7) association with pancreatitis;(8) presence of obvious sediment in bile

aspirated from the common bile duct;and

(9) demonstration of calculi in the bileducts prior to surgery.

These well-established indications for ex-ploration of the common duct should be judi-ciously observed, and the incidence of retainedductal stones should be reduced greatly as aresult. Operative cholangiography, while mostbeneficial in diagnosis of stones in the com-mon duct, should not be considered in any waya substitute for choledochostomy and carefulexploration when the aforementioned indica-tions are present.

In some cases an operative cholangiogrammay in fact disclose a pathologic condition

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that calls for exploration of the common ductwhen the classic indications for the procedureare absent. Small stones, free floating in theductal system, may be completely asympto-matic and produce none of the changes thatwould indicate the necessity for common ductexploration. Anomalies of the biliary tractthat may contribute to the formation of stoneshave been described by Ranney. 9 Unsuspectedstones or anomalies that may contribute tostone formation have been reported to occurin from 3 to 7 percent of patients subjectedto cholecystectomy for lithiasis. Operativecholangiography is most beneficial when theseare present.

A not infrequent source of retained ductalstones is the remnant of the cystic duct. Care-ful exposure and dissection of the cystic ductto its point of junction with the commonhepatic duct not only will facilitate removalof any stones that may be present in thisstructure but should serve to disrupt para-sympathetic nerve fibers originating from thevagus nerve and innervating the sphincter ofOddi. Puestow,7 in his discussion of the physi-ology of the extrahepatic biliary tract, indi-cated that the surgical disruption of the nervefibers parallel to the cystic duct causes lossof tone of the sphincter of Oddi so that thefree flow of bile is uninhibited by sphinctericaction and is modified only by changes in theintra-abdominal pressure. Such denervationof the sphincter of Oddi could well eliminatetwo probable sources of retention of ductalstones by permitting the passage of relativelysmall stones and preventing stasis in the duc-tal system.

As a result of long-standing choledochal dis-ease occasioned by the presence of stones, in-fection, and inflammation, there may be fibrosisat the sphincter. This might counteract anybeneficial effects obtained by denervation.When this is true, it may be advisable to per-form a duodenostomy with retrograde explor-ation of the common duct and sphincterotomy.The sphincter may be enlarged from 0.5 to 1cm. by an incision on the lateral margin, withcare being taken to avoid injury to the pan-creatic duct. Placement of the long-armed T-tube described by Cattell" through the sphinc-

ter and into the duodenum enhances healingwithout subsequent stenosis.

Many methods may be employed for the re-moval of stones after choledochotomy. Amongthem are irrigation with warm saline solutionor Tis-U-Sol and exploration of the ducts withprobes, dilators, forceps, and scoops. Recentlythe use of the Fogarty catheter has enhancedthe removal of stones, especially from the in-trahepatic ducts. Routine dilatation of thesphincter after exploration and, if indicated,sphincterotomy may be of value to permitsmall stones to pass and reduce the incidenceof new stone formation by permitting a freeflow of bile. A T-tube should be placed when-ever the common duct is explored. Completeand adequate exploration of the duct almostalways is followed by transient edema lastingfor from 5 to 8 days. Therefore, such a tubeshould permit the free flow of bile to protectthe liver and suture line from back pressure,which may occur if the duct is obstructed. Itshould be remembered that bile peritonitis inthe region of the common duct is one of thecommonest causes for subsequent developmentof obliterative cholangitis. Sawyers and asso-ciates," Rienhoff, 12 and others have publishedreports on series of cases in which the commonduct was explored and a T-tube was not usedroutinely. The hazards inherent in such prac-tice do not justify it.

In rare cases it may be believed that stonesare present in the ductal system and cannot beremoved by any of the methods described. Inview of the potential danger of subsequentobstruction by such stones, other protectivesurgical measures may be employed. A widecholedochoduodenostomy or choledochojej un-ostomy may be done, the size of the openingbeing limited only by the surgeon's judgmentand the length of available common duct. Suchanastomosis with the gastrointestinal tractmay permit passage of migrating large stonesfrom the intrahepatic ducts or may serve asa bypass when stones are lodged in the distalr ortion of the duct at the ampulla and cannotbe removed otherwise.

The choledochoscope introduced in 1963 hasproved to be of limited value in exploration ofthe common duct and disclosure of stones not

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detected by other means. Visualization of bothintrahepatic and extrahepatic parts of theductal system is greatly impaired by the lim-ited distensibility of the ducts by availablemethods and obstruction of vision by the pres-ence of bile and blood.

Secondary surgeryIn a group of patients with chronic cholecys-titis with or without associated cholelithiasisand choledocholithiasis who were undergoingsurgical treatment at the Mayo Clinic, thesurgical mortality rate was 0.9 percent.Among patients who underwent only chole-cystectomy, the rate was 0.5 percent or less.°When reoperation for retention of missed duc-tal calculi must be done, the mortality rate isincreased from three to four times. The op-erative mortality rate is further increasedwhen jaundice is present and when cholan-gitis or hepatic abscess is a complicating fea-ture. Patients undergoing reoperation usuallyhave had disease of the biliary tract for alonger period than those operated on for thefirst time. There usually is associated hepaticdisease secondary to chronic obstruction. Im-pairment of liver function is indicated by ele-vation of the alkaline phosphatase and glu-tamic oxaloacetic and pyruvic transaminasesin the serum, and there may be prolongedprothrombin time. Extra precautions shouldbe taken before secondary exploration of thecommon duct, and every attempt should bemade to localize the obstructing mechanismor other disease entity to be surgically treated.

Cholangitis is a serious complication andmay be disastrous. The surgeon should bemindful of the fact that stones or bile sedi-ment in the lower segment of the common ductmay not in fact cause the jaundice. Jaundicemay be produced by the obstruction of a majorintrahepatic biliary radicle. Stones in thisregion pose a most difficult surgical problem.Every effort should be made therefore to avoida second operation. There are certain non-surgical measures that may be consideredwhen serious complications are not imminent,when the biliary tract is incompletely ob-structed, or when calculi are small enough topass through the existing lumen. When stones

remain after a cholecystectomy, these condi-tions do not exist. When there is no T-tube inplace or the obstruction is above the T-tube, asecond operation probably is necessary.

A second operation is indicated when thereis complete obstruction, persistent or frequent-ly recurring pain, cholangitis, indicated byrecurrent chills and fever, or other complica-tions incidental to choledocholithiasis andcholangitis, such as progressive liver disease,bile peritonitis, or abscess formation.

Nonoperative treatmentThe simplest of the nonoperative measuresfor choledocholithiasis after cholecystectomyis watchful waiting. When a T-tube is in placeand adequate time has elapsed for the edemaof surgical trauma to subside, usually aboutthe eighth day, and obstructive symptoms per-sist with the clamping of the T-tube, a T-tubecholangiogram should be obtained. If an ob-structing mechanism is shown distal to theT-tube, drainage may be maintained by theT-tube and the patient may be reassured anddischarged with scheduled appointments forrepeat examinations via T-tube cholangiog-raphy. It has been demonstrated that patientsmay maintain an adequate nutritional statusfor an indefinite period without supplement-ary exogenous bile, and subsequent cholangio-grams may fail to show the obstructing mech-anism.

Attempts may be made to irrigate the ductalsystem, to disengage, disintegrate, dissolve, ormechanically flush out stones either into theduodenum or into the T-tube and subsequentlyto the outside. Stones lodged in the intra-hepatic radicles are not likely to be removedby such methods. Many chemical agents havebeen employed. 13 Some of them are hepato-toxic and should be used with extreme caution,especially if studies of liver function showimpairment. Best' described the use of hydro-choleretic agents and sphincteric relaxants ina "biliary flush." This has been reported tobe successful in removal of about 40 percentof stones retained in the common duct. Abiliary flush may be either mechanical orphysiologic. That is, the T-tube may be irri-gated directly with warm saline solution, or

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dehydrocholic acid and belladonna may begiven orally every evening at bedtime, withcitrate of magnesia before breakfast andcream of olive oil before the noon and eveningmeals. The biliary flush described by Best'consists of aspirating the bile contents fromthe T-tube and instillation of heated chloro-form on the first and second days, followed byether on the third day and glyceryl trinitratesublingually prior to the instillation of ether.The extreme discomfort associated with theinstillation of chloroform and ether may belessened somewhat by the introduction of atopical anesthetic such as Xylocaine and agradual but progressive increase in theamount of ether or chloroform employed. Thesimple administration of bile salts over weeksor months may result in the incidental or co-incidental disappearance of ductal calculi.This is especially useful in patients who donot have a T-tube in place. If obstruction isnot complete, certainly a therapeutic trial ofbile salts or a 3-day biliary flush regimen isindicated.

The results of nonoperative treatment forretained ductal stones can best be determinedby serial cholangiograms and laboratory ex-amination of the stool, urine, and blood, withtests that reflect changes incidental to thepresence of the ductal stones. Stones may befound in the stool as they are passed. If stonespersist after all available nonsurgical mea-sures have been employed, the decision to op-erate should be made in the light of variouscircumstances, not the least of which are thegeneral condition of the patient and his will-ingness to continue a period of close observa-tion with repeated physical and roentgeno-graphic examinations as indicated.

Addendum

The basic principles and techniques have notchanged in the past 2 years. However, othermechanical devices are employed for removalof ductal stones. Among these are Fogartycatheters and Dormeyer baskets passed viathe previously positioned T-tube.

Also, different chemical agents are employedfor dissolution or mechanical dislodging ofstones by irrigation. In current use is buffered

bile salt solution containing 100 7 millimoles ofsodium cholate or intraductal infusion of25,000 units of heparin every 8 hours to acontinuous saline drip.

Varied successes and failures were reportedby Arlie R. Mansberger, Jr., M.D., Professorand Chairman of Surgery, Medical College ofGeorgia, Augusta, who spoke at the AMA's122nd Annual Convention in New York City,June 23-28, 1973.

1. Best, R.R.: The incidence of liver stones associated withcholelithiasis and its clinical significance. Surg Gynecol Obstet 78:425-8, Apr 442. Berk, J.E., and Kaplan, A.A.: Choledocholithiasis. In Gastroen-terology. Edited by H.L. Bockus. Ed. 2. W.B. Saunders Co.,Philadelphia, 19653. Berk, J.E.: Choledocholithiasis. Am J Surg 56:96-101, Jan 424. Glenn, F.: Common duct exploration for stones. Surg GynecolObstet 95:431-8, Oct 625. Smith, S.W., et al.: Problems of retained end recurrent commonbile duct stones. JAMA 164:231-6, 18 May 646. Ferris, D.O., and Sterling, W.A.: Surgery of the biliary tract.Surg Clin North Am 47:861-76, Aug 677. Puedow, C.B.: Surgery of the biliary tract. pancreas andspleen. Ed. 4. Year Book Medical Publishers, Inc., Chicago, 19708. Mirizzi, P.L.: Operative cholangiography. Surg Gynecol Obstet65:702-10, Nov 879. Ranney, D.E.: Anomalies of the biliary tract. Mich J OsteopMed 29:9-11, May 6410. Cattell, R.B.: A new type of T-tube for surgery of the biliarytract. Bull Lahey Clin 4:197-204, Jan 4611. Sawyers, J.L., Herrington, J.L., Jr:; and, Edwards, W.H.:Primary closure of the common bile duct. Am J Surg 109:107-12,Jan 6512. Rienhoff, W.F., Jr.: Primary closure of the common duct.Ann Surg 151:255-60, Feb 6013. Goldman, B., Jackman, J., and Eastman, R.H.:: The man-agement of postoperative choledocholithiania. Another use for so-lution G. Surg Gynecol Obstet 81:621-4, Nov 45Glenn, F.: Complications following operations upon the biliarytract. In Complication, in surgery and their management. Editedby C.P. Artz and J.D. Hardy. Ed. 2. W.B. Saunders Co., Phila-delphia, 1967

(Submitted for publication in March 1972. Updating, as necessary,has been done by the author.)

This paper was presented at theFourth Annual Inquisition SurgicalForum held in Mexico City, March3, 1972. Dr. Anderson is a generalsurgeon (certified), practicing in De-troit.Dr. Anderson, 18830 Woodward Ave.,Detroit, Michigan 48203.

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