Overview

Although the era of intervention for choledocholithiasis can be traced to over a century ago, with the first successful common bile duct (CBD) exploration by Thornton in 1889 and with the introduction of catheter-based biliary decompression by Courvoisier and Kehr, significant advances and refinements did not occur until recent decades. For many years, open cholecystectomy and exploration of the CBD remained the standard treatment for patients with choledocholithiasis, and it was a procedure carried out on a regular basis by most general surgeons. During that era, the morbidity and mortality rates of CBD exploration were very low, the percentage of retained stones was only 1% to 3%, and in long-term follow-up, revisional surgery was necessary in only about 10% of the patients (Gonzalez et al, 1997; Hammarström et al, 1995; Neoptolemos et al, 1987; Targarona et al, 1996).

The past 3 decades, however, have seen major changes in the management of choledocholithiasis, prompted by the introduction of high-quality noninvasive imaging, the more widespread availability of percutaneous and endoscopic approaches to duct clearance (see Chapters 27 and 28), and the introduction of minimally invasive surgical approaches in the performance of choleycstectomy and CBD exploration (see Chapter 34). Although the overwhelming majority of cholecystectomies are now performed laparoscopically, laparoscopic exploration of the common bile duct (LCBDE) is infrequently performed, given the advanced skills typically required and the availability of endoscopic retrograde cholangiopancreatography (ERCP; see Chapter 18). In a recent survey of general surgeons practicing in a rural area of the United States, the preferred approach to choledocholithiasis was ERCP (75%), followed by laparoscopic (21%) and open (4%) exploration. Time constraints and lack of equipment were the main factors preventing the application of the laparoscopic technique for treating choledocholithiasis (Bingener & Schwesinger, 2006).

Despite these considerations, there remain indications for operative choledochotomy and, more specifically, for open exploration. This chapter presents a review of the clinical features of choledocholithiasis with an emphasis on the technical aspects of open CBD exploration.

Origin of Choledocholithiasis

Most CBD stones are secondary in nature, having migrated from the gallbladder. This is in contrast to primary CBD stones that originate within the CBD. The existence of such primary stones is suggested by their occurrence in patients with congenital absence of the gallbladder and in those whose CBD had been previously cleared at the time of prior cholecystectomy. The practice of routine cholangiography during the era of open cholecystectomy was common and demonstrated an incidence of choledocholithiasis approaching 10% in patients without clinically evident common duct involvement (McSherry & Glenn, 1980; Hampson et al, 1981; Doyle et al, 1982; Lygidakis, 1983; Coelho et al, 1984; Ganey et al, 1986; DenBesten & Berci, 1986; Girard, 2000). Some 10% to 15% of gallstone patients concomitantly suffer from bile duct stones. In the United States and other Western countries, CBD stones are predominantly secondary, although primary stones are more common in Asia. This is associated with the high incidence of intrahepatic bile duct stones seen primarily in Southeast Asian countries, Taiwan, Hong Kong, and Singapore (Kim et al, 1995; see Chapter 39). The relative prevalence of intrahepatic bile duct stones in all gallstone cases in Taiwan is extremely high (>50%), and coexisting intrahepatic and extrahepatic bile duct stones are found in approximately 70% of these. Furthermore, the gallbladder stones are primarily cholesterol or black-pigment stones, whereas most bile duct stones are brown-pigment (calcium bilirubin stones).

Clinical Features

The natural history of CBD stones is unpredictable, with many small stones passing spontaneously. In the era of open cholecystectomy, a healthy debate surrounded the need for routine intraoperative cholangiography in patients without clinical signs of choledocholithiasis. Detractors noted that although 10% to 15% of patients had cholangiographic findings of CBD stones when routine cholangiography was used, a much lower percentage of patients developed clinical sequelae of CBD stones in series that utilized a more selective approach to cholangiography.

More recent series of laparoscopic cholecystectomy with a selective approach toward cholangiography appear to confirm this same experience (Fogli et al, 2009). In one of the more notable recent experiences, Collins and colleagues (2004) identified filling defects consistent with stones in 4.6% of patients. In these patients, access was maintained for the performance of postoperative cholangiograms. At 48 hours, 26% of patients had a normal cholangiogram, and an additional 26% had evidence for passage of the stones by 6 weeks. Twenty-two patients (2.2% of total population) had persistent CBD stones at 6 weeks after laparoscopic cholecystectomy and underwent ERCP for retrieval (Collins et al, 2004).

Symptomatic presentations include biliary colic, jaundice, cholangitis, pancreatitis, or combinations of these. Infection in the setting of CBD obstruction gives rise to the classic triad of fever with chills, jaundice, and pain; in some patients this can be associated with clinical signs of sepsis (see Chapter 43). In the absence of infection, jaundice may occur in an often fluctuating manner, as the stone intermittingly obstructs passage of bile. Over long periods, this process can lead to secondary biliary cirrhosis. After biliary colic, pancreatitis is the second most frequent symptomatic presentation of CBD stones (see Chapter 53). Depending on the timing of cholangiography, CBD stones can be identified in up to 50% of patients. Patients who have symptomatic bile duct stones are at risk of experiencing further symptoms or complications if left untreated. More than one half of patients who had retained bile duct stones experienced recurrent symptoms during a follow-up period of 6 months to 13 years (Johnson & Hosking, 1987), and 25% developed serious complications (Caddy & Tham, 2006). Given the potentially serious nature of CBD stones, it is critical that an approach be adopted to identify patients with CBD stones and ensure their clearance.

Preoperative Diagnosis

The identification of patients with choledocholithiais in the absence of clinical signs requires a careful history and physical examination in conjunction with attention to routine blood work and abdominal ultrasound. Clinical, ultrasonographic, and serum chemistry data are sensitive in 96% to 98% and specific in 40% to 75% for identification of patients with choledocholithiasis (Alponat et al, 1997; Koo & Traverso, 1996; Trondsen et al, 1998). Liu and colleagues (2001) triaged patients before laparoscopic cholecystectomy using guidelines incorporating patient information obtained from clinical evaluation, serum chemistry analysis, and abdominal US and assigned them into four groups based on the level of suspicion for choledocholithiasis (group 1, extremely high; group 2, high; group 3, moderate; group 4, low). The occurrence of choledocholithiasis was 92.6%, 32.4%, 3.8%, and 0.9% for groups 1, 2, 3, and 4, respectively. Patient triage resulted in the identification of CBD stones during preoperative ERCP in 92.3% of the patients who were subsequently referred for endoscopic clearance. Many other groups have also demonstrated the value of liver function tests (LFTs) in predicting the presence of CBD stones (Peng et al, 2005; Sgourakis et al, 2005). Although the trends of bilirubin and alkaline phosphatase are more typically used, a raised gamma-glutamyltransferase level has been suggested to be the most sensitive and specific indicator of CBD stones. A value greater than 90 U/L has been proposed to indicate a high risk of choledocholithiasis, with sensitivity and specificity of 86% and 74.5%, respectively (Peng et al, 2005).

In patients identified to be at risk by clinical history and/or abnormalities in serum chemistries, if imaging and therapy are necessary, an efficient and thoughtful approach is required. Transabdominal ultrasound (TUS) is the most commonly used initial diagnostic tool for suspected biliary stones (see Chapter 13). It has the advantage of being noninvasive, widely available, and inexpensive; however, US is highly operator dependent. TUS has low sensitivity, 25% to 60%, for detection of bile duct stones, but it has a very high specificity, 95% to 100% (Sugiyama & Atomi, 1997; Amouyal et al, 1994). Indirect evidence, such as the presence of gallstones or biliary ductal dilation with a CBD diameter greater than 6 mm in the appropriate clinical setting, is predictive of bile duct stones.

Computed tomography (CT) scanning has a similarly low sensitivity in the detection of bile duct stones and is used primarily to document biliary dilation or to exclude other causes of biliary obstruction (e.g., a mass lesion; see Chapter 16). The role of helical CT cholangiography is still in evolution, particularly in the United States. Intravenously administered contrast agents combined with high-resolution helical scans and three-dimensional reconstructions can be very useful in diagnosing choledocholithiasis (Cabada Giadàs et al, 2002; Maniatis et al, 2003). The sensitivity of this technique can be as high as 97%, and the specificity is 85% to 96% (Polkowski et al, 1999; Cabada Giadas et al, 2002; Maniatis et al, 2003; Gibson et al, 2005; Kim et al, 2007). Although this accuracy is comparable to magnetic resonance cholangiopancreatography (MRCP), helical CT cholangiography is limited by 1) possible allergic reactions to the contrast agents, as high as 15% in one series using intravenous iotroxate (Gibson et al, 2005); 2) suboptimal ductal contrast opacification in the presence of significant jaundice, evidenced by bilirubin more than two or three times the upper limits of normal (Polkowski et al, 1999; Soto et al, 1999); and 3) limited visualization of intrahepatic duct branches, particularly when using oral contrast agents (Gibson et al, 2005; Chopra et al, 2000).

Since its introduction in 1991 (Wallner et al, 1991), MRCP has emerged as an accurate, noninvasive diagnostic modality for investigating the biliary and pancreatic ducts (Hallal et al, 2005) and has been recommended in some circles as the preoperative procedure of choice for the detection of CBD stones (Hallal et al, 2005; Taylor et al, 2002; Topal et al, 2003; see Chapter 17). MRCP provides excellent anatomic detail of the biliary tract and has a sensitivity of 81% to 100% and a specificity of 92% to 100% in detecting choledocholithiasis (Hallal et al, 2005). The accuracy of MRCP in diagnosing CBD stones is comparable with that of ERCP (see Chapter 18) and intraoperative cholangiogram (Hallal et al, 2005; Vargghese et al, 2000; see Chapter 21). It thus avoids the need for an invasive procedure in about 50% of patients (Demartines et al, 2000), allowing selective use of ERCP or surgical CBD exploration in those patients who require a therapeutic intervention. These results have led some practitioners to consider MRCP the new gold standard for biliary imaging (Hallal et al, 2005; Shanmugam et al, 2005), although MRCP may miss stones smaller than 5 mm in diameter. It can also underestimate the number of stones detected (Vargghese et al, 2000). MRCP is an expensive option that requires significant expertise for interpretation, and it may not always be readily available.

For years, the gold standard for preoperative visualization of the bile duct has been ERCP (see Chapter 18); however, the nonselective use of ERCP in all patients with suspected choledocholithiasis detects CBD stones in less than 50% (Behrns et al, 2008; Petrov et al, 2008) and results in over half of patients undergoing an unnecessary procedure, exposed to its associated morbidity and mortality. The first publications on the usefulness of the alternative, noninvasive modality, endoscopic ultrasonography (EUS), in diagnosing CBD stones appeared around 1990 (Amouyal et al, 1989; Edmundowicz et al, 1992; see Chapter 14). Since then, more than 25 prospective studies, incorporating more than 2500 patients with suspected choledocholithiasis, have shown excellent accuracy with EUS, as well as safety.

The overall diagnostic performance of EUS has been evaluated in two recent metanalyses (Garrow et al, 2007; Tse et al, 2008); the pooled sensitivity and specificity of EUS were 89% to 94% and 94% to 95%, respectively. A review of all randomized controlled trials of EUS-guided ERCP versus ERCP alone in patients with suspected choledocholithiasis demonstrated that by performing EUS first, ERCP may be safely avoided in two thirds of patients, and the use of EUS significantly reduced the risk of overall complications and post-ERCP acute pancreatitis (Petrov & Savides, 2009). The data suggest that the ERCP should be reserved solely for patients with a high probability of CBD stones.

Before the advent of laparoscopy, preoperative clearance of CBD stones with ERCP before open exploration was uncommon. Several well-performed studies did not demonstrate any improvement in morbidity or mortality with preoperative endoscopic sphincterotomy (Heinerman et al, 1989; Neoptolemos et al, 1988; Stain et al, 1991). One study showed an increase in morbidity when preoperative ERCP with sphincterotomy was added to open cholecystectomy compared with cholecystectomy and open CBD exploration (Stain et al, 1991). A Cochrane systematic review by Martin and colleagues (2006) showed that open surgery results in a lower primary treatment failure, fewer additional procedures, fewer average number of procedures required per patient, and less mortality. Largely based on these studies, preoperative ERCP with sphincterotomy was uncommon in the era of open cholecystectomy, and it did not become more widespread until laparoscopic approaches to cholecystectomy appeared.

When laparoscopic cholecystectomy was introduced, preoperative ERCP was frequently used for patients suspected of having choledocholithiasis, as evidenced by jaundice, elevated liver function tests, a history of pancreatitis, and a dilated biliary system. Even with these criteria, however, it is difficult to predict which patients will have choledocholithiasis, and a negative ERCP was performed in 40% to 70% of patients, because most of these abnormalities were caused by transient biliary obstruction secondary to stones that subsequently passed into the duodenum (Stain et al, 1991; Ponsky, 1992; Delorio et al, 1995; Cotton, 1993; Cuschieri et al, 1996).

Two prospective randomized controlled trials have compared preoperative ERCP with sphincterotomy followed by laparoscopic cholecystectomy during the same hospital admission with single-stage laparoscopic management (Cuschieri et al, 1999; Sgourakis et al, 2005). The results demonstrate equivalent success rates of duct clearance and patient morbidity for the two management options, but a significantly shorter hospital stay was reported with the single-stage laparoscopic treatment. Cuschieri and colleagues (1999) concluded that in fit patients (ASA I and II), single-stage laparoscopic treatment is the better option, and preoperative endoscopic sphincterotomy (ES) should be confined to poor-risk patients, such as those with cholangitis or severe pancreatitis.

Performing ERCP has clinical and financial costs that must be weighed against the likelihood of successful extraction of stones that otherwise would result in significant disease manifestation. Complications that include postprocedural pancreatitis, bleeding, infections, and perforations are not uncommon. ERCP has an overall complication rate of 10% and a mortality rate less than 0.5% (Ponsky, 1992; Delorio et al, 1995; Cotton, 1993; Davis et al, 1997). A recent systematic analysis of prospective studies has shown that complications continue to occur at a relatively consistent rate and that the majority of events are of mild to moderate severity (Andriulli et al, 2007).

Certain clinical situations mandate preoperative ERCP. Preoperative endoscopic drainage should be used in acute cholangitis for decompression and amelioration of sepsis (Cuschieri et al, 1999; Leung, 2003) and in patients with severe gallstone pancreatitis and evidence of persistent choledocholithiasis. Patients with other major comorbidities or limited life expectancy represent another indication for ERCP with endoscopic sphincterotomy (ES) and decompression (Cuschieri et al, 1999), often as the definitive management without cholecystectomy.

Common Bile Duct Exploration at Cholecystectomy

In the early 1970s, ES was introduced as a treatment modality for CBD stones. During the following decades, it gained wide acceptance as a less invasive, highly effective alternative for the treatment of biliary obstruction as a result of gallstones (see Chapters 18 and 27). However, in patients with residual stones in the gallbladder, subsequent cholecystectomy was considered necessary. In a prospective randomized trial, it was demonstrated that ES before open cholecystectomy did not lead to earlier recovery or less postoperative morbidity compared with primary open cholecystectomy combined with CBD exploration. In a prospective randomized trial published in 1995 by Hammarström and colleagues, an expectant policy after ES was compared with open cholecystectomy combined with CBD exploration. It appeared that 20% of the patients after ES alone needed cholecystectomy during follow-up.

Similar results were reported in 1996 by Targarona and colleagues. In this prospective randomized trial of high-risk patients, the policy of ES and subsequent open cholecystectomy was compared to ES alone. In their experience, patients who underwent elective open cholecystectomy had significantly fewer recurrent biliary symptoms (6% vs. 21%) and needed fewer readmissions (4% vs. 23%) than patients who did not undergo surgery after ES. (Targarona et al, 1996). Given the recognition that cholecystectomy is necessary in most patients with CBD stones, even in the presence of a papillotomy, the appropriate timing and method of CBD clearance must be considered.

In less developed health care environments, where endoscopic or percutaneous approaches to biliary decompression and stone clearance are limited, open cholecystectomy with bile duct exploration is indicated in patients with a strong clinical suspicion for common duct stones, such as those with abnormal LFTs or cholangitis, as well as when palpable stones are present in the CBD, or when stones are visualized on an intraoperative cholangiogram.

In more developed health care settings with access to endoscopic, radiologic, or laparoscopic expertise, there will still be some patients in whom an open approach to CBD exploration is required. These include 1) patients with large or impacted CBD stones, in whom biliary enteric drainage is indicated; 2) those with anatomic considerations that preclude endoscopic treatment, such as prior gastric resection, duodenal diverticulae, and so on; and 3) patients who require an open approach for cholecystectomy, including those with Mirizzi syndrome, biliary-enteric fistula, a high index of suspicion for cancer, and those with CBD stones demonstrated by palpation or cholangiogram.

Surgical Techniques for Exploration of the Common Bile Duct

Routine exploration of the CBD (see Chapter 29) should be through a supraduodenal choledochotomy, and the transduodenal route should be reserved for patients in whom stones cannot be removed readily from above. Although impacted stones at the ampulla may be broken down and removed by a supraduodenal approach, they probably should be removed by means of a transduodenal sphincteroplasty, because it is less traumatic in such circumstances (see Chapter 29).

The only reliable methods to confirm complete clearance of stones from the biliary tree are postexploratory choledochoscopy and cholangiography (see Chapters 21 and 28). The value of choledochoscopy has been confirmed by many authors (Dayton et al, 1984; Kappes et al, 1982; Nora et al, 1977). Postexploratory cholangiography also must be used and should be obtained before closure of the abdomen, not only because it can locate occasional missed stones, but also because it may reveal unsuspected disruption of the biliary ductal system. Although often regarded as unreliable because of the failure of contrast material to enter the duodenum and the difficulty of eliminating air bubbles, postexploratory cholangiography can be done reliably with attention to detail. Myatt and colleagues (1973) described a reliable technique that does not involve suture of the choledochotomy before postexploratory films are obtained. After exploration, a T-tube (at least 14 Fr) is left within the CBD to permit postoperative cholangiography and percutaneous extraction of retained stones if necessary. The techniques for exploration of the CBD are detailed in this section (see also Chapter 29).

The selective use of biliary-enteric drainage procedures is another method to decrease the incidence of subsequently symptomatic retained stones. Although we do not recommend routine biliary-enteric decompression at initial operation, it should be considered carefully in patients with multiple duct stones, particularly in dilated ducts in elderly patients and in those with a large stone, or stones, within a dilated duct. If these conditions pertain in an elderly or poor-risk patient, choledochoduodenostomy may obviate reexploration. Other indications include 1) the presence of irretrievable intrahepatic stones, 2) proven ampullary stenosis, or 3) an impacted ampullary stone.

Supraduodenal Choledochotomy and Exploration of the Common Bile Duct

Exposure

The liver is retracted superiorly with a broad-bladed, slightly curved retractor. This retractor should be deep enough to displace the liver but not so curved as to traumatize it. The curved, broad-based Hartmann (“sweetheart”) retractor often serves this purpose well. A pack should be put over the hepatic flexure of the colon down to the hepatorenal pouch and the medial part of the duodenum. This pack is retracted by a similar, broad-bladed retractor to prevent the colon or duodenum from obscuring vision (Fig. 35.1). The lesser omentum and stomach are retracted to the left after placement of another pack. The gallbladder usually is removed before exploration of the CBD, because it may obstruct vision, although in some cases it can be a useful aid to retraction. Palpation of the CBD and handling of its lower part during exploration and subsequent choledochoscopy cannot be done properly without having performed a classic Kocher maneuver (Fig. 35.2).

FIGURE 35.1 Exposure of the common bile duct by packs and retractors.

FIGURE 35.2 A, The gallbladder has been removed. The dotted line indicates the incision in the retroperitoneum to allow mobilization of the duodenum by the Kocher maneuver (B).

Choledochotomy

The site of the choledochotomy depends on several factors. Choledochoduodenostomy may become necessary (see Chapter 29), so the opening must be in the lowest part of the supraduodenal CBD that is consistent with an easy subsequent anastomosis (Figs. 35.3 and 35.4). A distal choledochotomy is recommended so that as much as possible of the CBD is left proximally, in case the duct is needed for some further procedure (e.g., repair of a stricture) in this part of the duct. Another reason why the choledochotomy should be placed distal and close to the duodenum is that the usual distance from this point to the papilla measures 7 cm or more. This is the exact length of the rigid choledochoscope used to do CBD exploration, and a clear view of the papilla of Vater is obtained. The anatomy of the cystic duct is so variable that care must be exercised to open the correct duct (see Chapter 1B). A cystic duct lying anterior or closely applied to the CBD can be easily opened in error (Fig. 35.5). Bile is aspirated by gentle suction, and a specimen should be sent for culture.

FIGURE 35.3 The common bile duct is opened just above the duodenum to leave room for a choledochoduodenostomy if necessary.

FIGURE 35.4 Two fine stay sutures of 3-0 polydioxanone suture or 3-0 polyglactin 910 (Vicryl) are used to lift and render the common bile duct (CBD) tense for an incision about 1 to 2 cm long, depending on the size of the duct and the size of the stones. If the CBD is not made tense, damage can be done to the posterior wall, or an irregular incision can be made.

FIGURE 35.5 A, The cystic duct may lie anterior to the common bile duct (CBD) and may be opened in error. B, The cystic duct may run parallel to the CBD with a low entrance, mimicking a dilated duct.

Exploration of the Duct (See Chapter 29)

Exploration should be as atraumatic as possible, and the use of rigid instruments should be avoided (Gunn, 1983; Orloff, 1978). Grasping forceps of any type may catch the wall of the duct and cause damage and possible late stricture formation. Bougies traditionally have been used, but metal instruments can create a false passage into the duodenum or the pancreas. The Fogarty balloon catheter has been found to be suitable for CBD exploration (Fogarty et al, 1968; Fox & Gunn, 1984).

The Fogarty probe is held in long forceps and introduced into the CBD. The forceps is held in the surgeon’s dominant hand (Fig. 35.6), and the catheter is passed into the duodenum. The balloon is inflated, and the catheter is withdrawn until it impinges against the papilla (Fig. 35.7). As already mentioned, the duct is normally about 7 cm from the point of choledochotomy to the duodenum. The second part of the duodenum is palpated, and the balloon is identified to determine the site of the papilla in case duodenotomy is necessary. Any stone usually can be felt against the shaft of the catheter. The balloon is deflated and gently withdrawn through the papilla, and this can be detected by a sudden easing of the pull on the catheter; the balloon is reinflated immediately. The catheter is held by the syringe in the surgeon’s nondominant hand, and the degree of inflation is controlled by the thumb and the plunger. With gentle traction superiorly from long forceps held in the surgeon’s dominant hand, the catheter is gradually pulled up to the choledochotomy site (Fig. 35.8), with care being taken to prevent any stone slipping into the proximal biliary tree. If the traction is anterior rather than superior, there is the risk of lacerating the opening into the duct (Fig. 35.9), and the risk is increased when the opening in the duct is longitudinal. The procedure is repeated until the distal duct is considered to be clear.

FIGURE 35.6 A Fogarty catheter is fed into the duct with forceps using the dominant hand. The operator’s nondominant hand is used to grasp the mobilized duodenum, which allows palpation of the passage of the catheter and of any stones within the intrapancreatic portion of the common bile duct.

FIGURE 35.7 A, The Fogarty catheter is attached to a syringe, and the balloon is inflated in the duodenum. B, The Fogarty catheter is retracted with the balloon against the papilla. C and D, The balloon is deflated and gently withdrawn until it slips through the papilla; the balloon is then reinflated.

FIGURE 35.8 A, The balloon is withdrawn gently, revealing the stone. B, Long forceps can be used to obstruct the common hepatic duct to prevent the stone from slipping upward.

FIGURE 35.9 Angled traction on the Fogarty catheter results in tearing of the lower end of the choledochotomy.

The catheter is withdrawn and reinserted upward into each of the main hepatic ducts, and the procedure is repeated again. The balloon inflation needs to be correct: overinflation could damage the ducts, and underinflation could result in missing any stone that is present. Correct inflation can be achieved by inflating the balloon until the tension of the syringe plunger can be felt in the fingers. This tension is maintained as the catheter is withdrawn into the gradually widening duct.

It is important to remove the stone when it appears at the choledochotomy opening and to avoid letting it fall into another part of the duct. The second step in CBD exploration is to irrigate the duct with saline. Small stones, sludge, and debris can be flushed into the duodenum or back into the choledochotomy opening by irrigating the ductal system. The last step in this technique is to pass the Fogarty catheter again into the duodenum, inflate the balloon, and retract it against the papilla. While the catheter is held in the surgeon’s dominant hand, the index and middle fingers of the other hand are placed posterior to the duodenum with the thumb anterior; this allows palpation of the duct against the wall of the catheter for any residual stones.

Postexploratory Investigations

Following exploration, the surgeon must make every effort to ensure that the duct system is normal.

Choledochoscopy (See Chapter 21)

Choledochoscopy is the established method to ensure that the duct system is normal. Modern instruments are small enough to allow visualization of the major right and left hepatic ducts and intermediate hepatic ducts and to allow visualization of the orifices of the smaller biliary radicles. Some surgeons experienced in choledochoscopy recommend exploration of the CBD and removal of stones under direct vision using the choledochoscope (Berci, 2000).

T-Tube Cholangiography

After insertion of a T-tube and closure of the choledochotomy, T-tube cholangiography is another option for postexploratory investigation. With proper technique and use of fluoroscopy, T-tube cholangiography is an excellent tool for detecting residual stones after CBD exploration (Fig. 35.10). The cystic duct stump, a possible location of residual stones, can be delineated, and incorrect placement of the T-tube can be detected to prevent complications after the operation. In case of residual stones, the T-tube has to be removed, and the duct needs to be explored again; this necessitates a second suture of the CBD, which is a major disadvantage of T-tube cholangiography. The technique described by Myatt and colleagues (1973), whereby the cholangiogram is done before closure of the duct, can be valuable in this regard.

FIGURE 35.10 A postexploration T-tube cholangiogram identifies a residual stone in the intrahepatic bile ducts that was missed during operative exploration of the bile duct.

T-Tube Drainage

The standard practice is to use a T-tube to allow spasm or edema of the sphincter to settle after the trauma of the exploration. Failure to drain the duct might result in a buildup of pressure in the extrahepatic ductal system and cause leakage at the disruption of the closure of the duct, along with biliary peritonitis. Another important reason for the use of a T-tube is for the detection and subsequent treatment of retained stones. In the event of a retained stone, the T-tube can be useful later for interventional radiologic techniques through the tract created by the tube (Fig. 35.11).

FIGURE 35.11 A, Faceted retained distal common bile duct (CBD) stone on T-tube cholangiography 1 week after operation. The T-tube is inserted in the common hepatic duct above the confluence of the cystic duct. B, The retained CBD stone is ensnared in the wire basket before extraction. This stone measured 5 mm in diameter and was extracted intact through the sinus tract of a 14-Fr T-tube.

The use of a T-tube creates a fistula between the skin and the lumen of the duct, and both are potentially contaminated surfaces; the tract of the fistula crosses the peritoneal surface. The size of the T-tube should be adapted to the diameter of the CBD; 14 Fr is the smallest size that should be used, if a satisfactory tract is to be left for subsequent interventional radiology. A significant proportion of patients who have choledochoscopy and cholangiography have a greatly reduced number of residual stones, but a wise surgeon should accept that stones occasionally are left.

T-Tube Placement

First, the limbs of the T-tube must be shortened (Fig. 35.12A). T-tubes can become obstructed, particularly if they are tight fitting, and they can be difficult to extract. This situation can be avoided by cutting off a strip of the wall (Fig. 35.12B). The practice of dividing the back wall of the T-tube makes subsequent interventional radiology more difficult, because the guidewire lodges in the posterior defect. In the main, this problem can be avoided by making the length of the T-tube appropriate or by limiting the division of the T-tube. The modified T-tube is held in Desjardin forceps, which conveniently grasps the T-junction of the tube, allowing it to be slipped into the choledochotomy (Fig. 35.13). The long limb of the tube is placed at the lower end of the opening, and repair is begun just above the upper apex of the incision using continuous or interrupted resorbable material. The final stitch should close the opening against the T-tube (Fig. 35.14).

FIGURE 35.12 A, The T-tube is modified by shortening the limbs to prevent proximal obstruction and distal entry into the duodenum. B, A T-tube is modified by removing half the diameter to prevent obstruction and enable easy removal.

FIGURE 35.13 The T-tube is introduced by Desjardin forceps.

FIGURE 35.14 The choledochotomy closure is begun above with the T-tube emerging at the lower end of the repair.

Avoiding Problems in the Closure of the Choledochotomy

Care must be taken that the wall of the T-tube is not caught in one of the sutures, and the end of the suture should not be tied around the tube. Either of these faults may result in the tearing of the duct when the tube is withdrawn. The proximal limb of the T-tube should not enter one of the hepatic ducts because this can produce obstruction (Fig. 35.15), and the distal end must not enter the duodenum, because this can act as a siphon. In addition, a tube through the papillary orifice may incite pancreatitis. The correct position of the T-tube is with the long limb emerging under the costal margin laterally (Fig. 35.16). This position facilitates radiologic techniques for later postoperative removal of stones should this be necessary. A suction drain is placed on the right, within the abdomen as high as possible in the hepatorenal pouch.

FIGURE 35.15 A, The suture must not catch the tube as shown here. B, The T-tube limb should not enter the hepatic duct, as shown here. C, The distal end of the T-tube should not enter the duodenum, as shown here.

FIGURE 35.16 The T-tube should be brought out lateral to the wound, and a closed-suction drain should be placed in the hepatorenal space beneath the liver.

Postoperative Management

Initially, bile is allowed to drain freely into a bile bag to allow any spasm or edema of the sphincter to settle before testing the suture line of the choledochotomy. The volume drained varies, with the amount decreasing as flow increases through the sphincter. If the volume drained remains high or increases, the reason should be established. This increased volume may be due to continuing distal obstruction or to the distal limb lying within the duodenum. Similarly, there is a problem if there is no drainage of the bile, or if bile drains around the T-tube; the tube may have become blocked or dislodged from the duct.

The answer to all these problems is revealed by T-tube cholangiography. Provided that there have been no problems, subsequent management is aimed at waiting for the bile to flow easily through the papilla into the duodenum, and the bile bag should not be lifted or clamped. A T-tube cholangiogram is taken about 5 to 7 days after the operation. If it appears normal, the tube is removed on day 7 or 8 by gentle traction.

If there are residual stones or unclear findings on T-tube cholangiography, it is a good practice to repeat the procedure several days later. If a stone is still seen, it is managed initially by sending the patient home with a sealed drainage system and instructions to open the drain and connect it to a bag in the event of any problems. After about 5 weeks, further cholangiography is carried out. If the stone is still present, it is extracted via interventional radiology or endoscopic papillotomy (Fig. 35.17).

FIGURE 35.17 Balloon extraction of a single stone (arrow).

Transduodenal Sphincteroplasty

Transduodenal sphincteroplasty (see Chapter 29) has a place in the management of CBD stones, particularly if a stone is impacted at the ampulla or with failure of ES, in patients with Billroth II gastrectomy, and in patients with pancreatitis when a drainage procedure of the duct of Wirsung is indicated (Lehman & Sherman, 1998). Similarly, hydatid cyst remnants and membranes can be readily extracted from the CBD. Exploration may extend to the left and right hepatic ducts, and angled Randall forceps are useful for this purpose.

Sphincteroplasty consists of suturing the outer edge or both edges of a surgical sphincterotomy to avoid possible future stenosis of the incision. The stitches achieve hemostasis of the incision margins and help to avoid possible leakage of the duodenal contents should the excision extend beyond the common portion of the sphincter, incurring the risk of retroduodenal perforation. Transduodenal sphincteroplasty is contraindicated in the presence of a large CBD (>2 cm) or where there is a long suprasphincteric stricture. It also should not be attempted in the presence of a duodenal diverticulum or where there is severe periampullary inflammation.

Indications

The most common indications for transduodenal sphincteroplasty relate to bile duct stones and cholangitis.

Stones Impacted in the Distal Ampullary Region

An impacted stone is often readily palpable, and the incision may be made safely using the stone as a guide. In such cases, extraction through a supraduodenal choledochotomy is often impossible without undue risk of creating a false passage and without significant risk of postoperative pancreatitis.

Multiple and Recurrent Common Bile Duct Stones

In cases of multiple and recurrent CBD stones, sphincteroplasty should provide long-term biliary drainage. When 20 or more stones are removed from the CBD, it is probable that one or more stones are still present (Stain et al, 1991). In this situation, choledochoduodenostomy or sphincteroplasty yields excellent results.

Papillary Stenosis

Papillary stenosis is encountered less frequently than in the past. When it is found at operation, transduodenal sphincteroplasty ensures good biliary drainage and prevents restenosis (Ramirez et al, 1994). ES is technically successful in only 60% to 80% of cases, and mortality rate exceeds 1% (Seifert et al, 1982). In addition, sphincterotomy for papillary stenosis is five times more likely to lead to restenosis than if the same procedure is performed for calculi (Tzovaras & Rowlands, 1998).

Pyogenic Cholangitis (See Chapter 43)

If papillary stenosis or CBD stones or both exist together with cholangitis, transduodenal sphincteroplasty can be an excellent procedure for definitive biliary drainage.

Chronic Pancreatitis and Acute Gallstone Pancreatitis (See Chapter 53, Chapter 54, Chapter 55A, Chapter 55B )

In chronic pancreatitis, some authors report good long-term results with transduodenal sphincteroplasty alone (Hacaim et al, 1994) or in addition to transpapillary septectomy (Moody et al, 1983) or with other drainage procedures of the duct of Wirsung (Kestens et al, 1996). The presence of a stone at the lower end of the CBD or pancreatic duct may cause biliary pancreatitis, and transduodenal sphincteroplasty with clearance of the CBD is a treatment option.

Technique

Sphincteroplasty consists of the incision of the common portion of the sphincter of Oddi (Fig. 35.18) with partial suture of the incision margin. By this procedure, the sphincters of the CBD and the duct of Wirsung are not involved, and their functions are not impaired. The procedure also can be called a subtotal lower sphincteroplasty (Fig. 35.19; Stefanini et al, 1977). The approach to the sphincter of Oddi is through a minimal duodenotomy in the second part of the duodenum.

FIGURE 35.18 A section of the sphincter of Oddi. Note the distinction between the papilla, the common portion of the sphincter, and the sphincters of the common bile duct and duct of Wirsung.

FIGURE 35.19 Subtotal lower sphincteroplasty involves only the papilla, whereas the common bile duct and the duct of Wirsung are preserved.

Preparation, Position of the Patient, and Incision

Preoperative preparation is routine. A nasogastric tube is introduced before operation and is maintained until postoperative day 3 or 4. The patient is placed in a supine position on a radiotransparent operating table. A transverse incision below the right costal margin is preferred (Vogt & Hermann, 1981). This incision allows optimal light and excellent access, it is particularly suitable in obese patients, and the incidence of postoperative incisional hernia is probably lower than with vertical and oblique incisions. The incision of the abdominal wall follows a transverse line, from the midaxillary to the median line at the level of the eleventh and twelfth ribs (Fig. 35.20).

FIGURE 35.20 Transverse subcostal incision offers excellent exposure with a low incidence of postoperative incisional hernia.

Preparation of the Operative Field and Exposure

The abdomen is opened, and a large retractor is positioned at the upper margin of the wound. The right flexure of the colon is displaced inferiorly, and the stomach is displaced to the left by means of two surgical pads. Viscera are maintained in this position with two large, curved Deaver retractors. For the performance of the sphincteroplasty, extended mobilization of the duodenum and pancreas (Kocher maneuver) is mandatory (Moody et al, 1983). The assistant surgeon displaces the second portion medially and forward, and the peritoneum is incised posteriorly along the curved lateral margin of the duodenum. The mesocolon of the right colic flexure is cleared inferiorly. At this point, the assistant surgeon also should displace the duodenum superiorly (see Fig. 35.2). Access is provided to the avascular space between the posterior aspect of the head of the pancreas anteriorly and the perinephric fat and inferior vena cava posteriorly; elevation of the structures should reach the left margin of the inferior vena cava. It is important to expose and mobilize the third portion of the duodenum to allow easy access to the papilla and for closure of the duodenotomy without tension (Fig. 35.21).

FIGURE 35.21 It is important to expose and mobilize the third portion of the duodenum to easily identify and operate on the papilla and allow facile closure of the duodenotomy.

Duodenotomy

Duodenotomy is performed in the lateral duodenal wall by surgical diathermy. The cut is 10 to 15 mm long immediately above the inferior knee of the duodenum, with the surgeon taking account of the fact that the papilla usually is located at the junction of the lower third with the upper two thirds of the second portion of the duodenum (Fig. 35.22). The duodenal incision may be longitudinal or transverse; both types are suitable, provided that the suture of such incisions is always transverse. We prefer a longitudinal incision, because if the retractor on the duodenum widens the duodenotomy, this occurs longitudinally. In the case of a transverse duodenotomy, any inadvertent extension would cause a transverse enlargement of the wound.

FIGURE 35.22 The duodenotomy is performed above the junction of the second and third portions of the duodenum; the surgeon takes into account that the papilla usually is located at the junction of the upper two thirds and lower third of the second part of the duodenum.

Identification of the Papilla

After the duodenal incision, the papilla is readily shown on the medial duodenal wall in 15% to 20% of patients. It appears as a roundish elevation with a central orifice. When the papilla is not readily visible, it should be detected by displacement and flattening of the mucosal folds. This should be done with great care to avoid tearing of the mucosa, which would hinder good exposure. Identification of the papilla under direct vision is possible in 80% of patients. If this is not the case, digital palpation can be used running the forefinger, introduced through the duodenotomy, across the medial duodenal wall. The papilla is identified as a small elevation (Fig. 35.23). If digital palpation fails, a small (5 to 6 Fr) Nélaton catheter can be introduced via the cystic duct stump and advanced downward to emerge at the papilla. This maneuver should never be performed with rigid catheters, because this may result in the formation of false passages.

FIGURE 35.23 If the papilla is not easily seen, a small Nélaton catheter is introduced through the cystic duct stump until it is seen to protrude from the papillary orifice. The forefinger, introduced through the duodenotomy, detects the papilla as a small, thick elevation.

Sometimes a very small papilla is detected, and its catheterization is difficult or impossible. In such cases, the orifice is probably that of the duct of Santorini. The major papilla should be searched for in a lower position.

Sphincteroplasty

After the papilla has been identified, it is exposed by gentle extraction with an Allis or similar clamp. This clamp is applied laterally, never medially, to avoid trauma to the duct of Wirsung (Fig. 35.24; Partington, 1977). A Nélaton catheter (4 to 5 Fr) is introduced from the outside or via the cystic duct. Following the line of the catheter—and avoiding plastic catheters, which melt when surgical diathermy is applied—the surgeon makes a cut using surgical diathermy. This cut is made superiorly (at the 11 o’clock position) for 4 to 5 mm (Fig. 35.25). We prefer surgical diathermy, because the instrument ensures good hemostasis. When a sample for biopsy is required, it should be obtained with a scalpel and be taken only from the outer margin of the incision. Possible bleeding from the cut, usually modest, can be arrested with a stitch. After sphincterotomy, two or three stitches are placed between the duodenal mucosa and the wall of the CBD on the outer margin using an atraumatic needle and 3-0 silk. Traction is applied to these sutures, and incision of the sphincter is extended for another 6 to 7 mm with sutures placed every 2 to 3 mm, all laterally, until the entire common tract of the sphincter of Oddi has been incised (Fig. 35.26). The incision is complete when it is 10 to 12 mm long and an appropriate forceps can be easily introduced (Fig. 35.27). Its entry into the CBD allows an abundant flow of bile owing to distension of its sphincter. Sutures should be placed only on the outer margin of the sphincterotomy to prevent the risk of damage to the duct of Wirsung. The opening of the duct of Wirsung usually is identified as a small orifice from which clear, colorless pancreatic juice flows.

FIGURE 35.24 The duodenotomy is kept open by a suitable retractor placed in the upper margin of the duodenal incision. The papilla is exposed by gentle traction with an Allis clamp placed laterally, never medially, to avoid trauma to the duct of Wirsung.

FIGURE 35.25 With a Nélaton catheter as a guide, a cut is made using surgical diathermy on the medial wall of the duodenum extending superiorly and slightly externally (11 o’clock position). With diathermy, good hemostasis is achieved.

FIGURE 35.26 After sphincterectomy is performed, several stitches are placed between the duodenal mucosa and the wall of the common bile duct (CBD) using an atraumatic needle and 3-0 suture. Sutures should be placed only on the outer margin of the sphincterotomy to avoid the risk of damaging the duct of Wirsung, which in its distal portion runs inferiorly and medially along the length of the CBD.

FIGURE 35.27 Sphincteroplasty is completed when the incision is 10 to 21 mm long, and a Randall forceps can be introduced easily into the common bile duct to extract stones or other foreign bodies.

Instrumental Exploration of the Common Bile Duct

After sphincteroplasty, instrumental exploration of the CBD and extraction of stones is performed (Speranza et al, 1982). An angled Randall forceps is introduced into the CBD, and the left and right hepatic ducts are carefully explored. The maneuver should be repeated several times to extract all stones. The next step is to rinse with saline solution, introduced under slight pressure with a Nélaton catheter (8 to 9 Fr) and abruptly withdrawn so that small fragments flow downstream with the siphoning (Fig. 35.28). Other means to extract stones from the CBD are with a Fogarty catheter and Dormia basket. The problem of residual stones is best prevented with choledochoscopy; the endoscope is introduced via the sphincteroplasty.

FIGURE 35.28 After the extraction of stones, the common bile duct is rinsed with saline solution introduced under slight pressure with a Nélaton catheter and with subsequent siphoning so that small fragments can run downstream.

Duodenal Closure

As already emphasized, initial longitudinal duodenotomy always should be closed transversely to avoid stenosis of the duodenum. First, the superior and inferior margins of the incisions are approximated, and the resulting gaps are sutured with two extramucosal, nonabsorbable purse-string sutures. Three or four nonabsorbable seromuscular sutures are added (Fig. 35.29). The suture should not be under tension, and for this reason preliminary extended mobilization of the duodenum and pancreas is mandatory. The operation is now complete, and the wound is closed without abdominal drains.

FIGURE 35.29 The duodenotomy always should be closed transversely to avoid stenosis of the duodenum. A, The superior and inferior angles are approximated. B, The resulting lateral gaps are sutured with two extramucosal nonabsorbable purse-string sutures. C, Three to four nonabsorbable seromuscular stitches are added as a second layer. The sutures should not be under tension.

Comment

It is not necessary to perform transduodenal sphincteroplasty combined with supraduodenal choledochotomy, which has a higher associated mortality rate (Scheridan et al, 1987). The cystic duct remnant may be used to introduce a Nélaton catheter to assist recognition of the papilla. There is no need to insert a T-tube, which lengthens the hospital stay and may predispose the patient to stenosis and infection of the CBD (Ratych et al, 1991; Scheridan et al, 1987). Patients with no drainage tubes or complications may be discharged on postoperative day 5 or 6.

Review of Reported Results

In a retrospective analysis of 25,541 transduodenal sphincteroplasties done by 130 surgeons in different countries, early transduodenal sphincteroplasty–related complications were bleeding (0.65%), acute pancreatitis (0.60%), dehiscence of the duodenal closure (0.55%), and cholangitis (0.50%), for an overall morbidity rate of 2.3% and a mortality rate of 0.8% (Negro et al, 1984). A retrospective study (Sellner et al, 1988) found that the factors affecting mortality in 2.1% of 333 patients (but only in 0.9% for sphincterectomy-related complications) were age older than 70 years and a bilirubin level greater than 85 mmol/L, diabetes, renal failure, and coagulopathy. The mortality rate increased when supraduodenal choledochotomy was combined with transduodenal sphincteroplasty and when a T-tube was used (Sellner et al, 1988). Transduodenal sphincteroplasty alone (Hacaim et al, 1994) or associated with transampullary septectomy (Kelly & Rowlands, 1996) has led to good long-term results in patients with chronic and acute recurrent pancreatitis, even in cases with pancreas divisum and in selected patients with abdominal pain of hepatobiliary origin.