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cbd calculus

ESWL is an effective non-invasive treatment modality that can be performed safely on an outpatient basis, without use of general anaesthesia. For this reason it is a useful treatment option in patients with difficult common bile duct calculi who are considered to be poor candidates for surgery.

In this case, given the patient’s age and comorbidities it was decided that this was the treatment of choice. Biliary drainage was achieved during initial ERCP using a pigtail stent.

At repeat ERCP the pigtail stent was removed and the cholangiogram shows no evidence of calculi with satisfactory drainage from the common bile duct.

Treatment options for common bile duct stones (CBD, common bile duct; ERCP, endoscopic retrograde cholangiopancreatography; ESWL, extracorporeal shockwave lithotripsy).

Q2: What does the post-treatment ercp film (fig1 in questions; see p 178) show?

Spontaneous passage of calculi occurs in up to 10% of patients, with 80% requiring removal of stone fragments during repeat ERCP. 1 Although recurrence of bile duct calculi is estimated at 14% after one year, most of these are amenable to endoscopic treatment. 2

The patient then underwent one session of high energy ESWL, during which the calculus was targeted by ultrasonography. 1, 2 Studies have shown that between 20% and 50% of patients will require more than one treatment session. 3, 6, 7 The success rate of this procedure, with complete clearance of the common bile duct is between 80% and 90%. 1– 3, 6

Traditionally such patients have been referred for surgical exploration of the common bile duct but this procedure is not without risk, particularly in elderly patients or those with major medical comorbidities. 4

Final diagnosis

These are summarised in fig 1. Endoscopic extraction of common bile duct stones after spincterotomy and mechanical lithotripsy has a success rate of up to 95% and is considered the treatment of choice. 1, 2 The reason for failure in this case was the large size of the bile duct calculus. Other reasons include bile duct strictures, unusual anatomy, and calculi beyond reach of the wire basket. 1– 3

Extracorporeal shock wave lithotripsy (ESWL) was investigated initially for treatment of gallbladder stones, but a high stone recurrence rate has limited its use in this condition. 5 In recent years high energy ESWL has been used with more promising results in high risk patients with common bile duct stones.

Cbd calculus

Although intraoperative cholangiography was attempted in all cases except for 2 patients with a documented contrast allergy, it was successful in 962 patients (96%). Of the patients in whom cholangiography was successful, 46 patients had filling defects in the common bile or common hepatic duct, and 6 others had a dilated common bile duct (>10 mm). In these cases the cholangiogram catheter was left in situ. In 4 other cases, the catheter was left because of either nonemptying of CBD despite hyoscine butylbromide (1 patient) or concerns about abnormal anatomy (3 patients). These studies were normal at 48 hours.

Patient selection for biliary intervention has been flawed partly because of the lack of a sensitive noninvasive imaging modality and also because the incidence and natural history of asymptomatic common bile duct calculi has not been determined in patients selected for laparoscopic cholecystectomy. In this study of patients undergoing laparoscopic cholecystectomy, we prospectively define the true incidence of common bile duct calculi and their early natural history by undertaking intraoperative cholangiography and delayed postoperative cholangiography in those who had demonstrable intraoperative filling defects in their bile ducts.

RESULTS

The calculus size was similarly determined using the size 4-Fr ureteric cannula. The largest calculus for each patient was recorded and the sizes varied between 2 and 15 mm. The number of calculi within the CBD ranged between 1 and more than 50 for the patients who cleared their ducts (Figs. 1 and 2) and was between 1 and 8 for those who had retained calculi at 6 weeks. There was no relationship between calculus size and bile duct clearance; stones less than 5 mm were often retained whereas stones of 15 mm passed spontaneously.

Operative cholangiography was attempted in all patients using a 4-Fr or 5-Fr ureteric catheter with a nylon stylet (Porges SA, Cedex, France). This catheter is marked at 1-cm intervals and has 2 distal apertures located 1 and 2 cm proximal to the tip. This was introduced through the abdominal wall via a needle through a separate skin puncture wound and advanced through the cystic duct, if possible to the 5 cm mark, where it was secured with 2 titanium clips (Ligaclip®Extra, Ethicon). The plastic stylet was then withdrawn and backflow of bile through the tube was awaited. Two syringes (one containing saline and the other contrast–30% Hypaque solution) were then connected to the tube by a 3-way stopcock attached to a butterfly needle. Bile was aspirated through the connecting system to eliminate gas bubbles. The catheter was then flushed through with saline solution while inspecting at the site of insertion into the cystic duct for leakage. Leakage occurred rarely, mostly when the catheter was not sufficiently advanced through the cystic duct. In these circumstances, repeat cannulation was attempted with a new catheter, and if unsuccessful, the cholangiogram was abandoned.

Results:

Operative cholangiography was attempted in 997 consecutive patients and was accomplished in 962 patients (96%). Forty-six patients (4.6%) had at least one filling defect. Twelve of these had a normal cholangiogram at 48 hours (26% possible false-positive operative cholangiogram) and a further 12 at 6 weeks (26% spontaneous passage of calculi). Spontaneous passage was not determined by either the number or size of calculi or by the diameter of the bile duct. Only 22 patients (2.2% of total population) had persistent common bile duct calculi at 6 weeks after laparoscopic cholecystectomy and retrieved by endoscopic retrograde cholangiopancreatography.