Canadian Association of Radiologists Journal xx (2013) 1e6

www.carjonline.org

Abdominal Imaging / Imagerie abdominale

Dilatation of the Bile Duct in Patients After Cholecystectomy:

A Retrospective Study
David Landry, MD, B Enga, An Tang, MD, FRCPCa, Jessica Murphy-Lavall
ee, MD, FRCPCa,*,
Luigi Lepanto, MD, FRCPCa, Jean-S
ebastien Billiard, MDa, Damien Olivi
e, MDa,
Marie-Pierre Sylvestre, PhDb
a
Department of Radiology, University of Montr
eal and CRCHUM, H^opital Saint-Luc, Montr
eal, Qu
ebec, Canada
b
Biostatistics Services, University of Montreal Hospital Research Center (CRCHUM), Centre de recherche du CHUM, Montr
eal, Qu
ebec, Canada

Abstract

Purpose: Retrospective assessment of impact of cholecystectomy, age, and sex on bile duct (BD) diameter.
Materials and Methods: We retrospectively reviewed abdominal contrast-enhanced multidetector computed tomography and laboratory
reports of 290 consecutive patients (119 men; mean age, 55.9 years) who presented without cholestasis to the emergency department of our
institution between June 2009 and August 2010. BD diameters were measured in 3 locations, by 2 independent observers, twice, at 1-month
intervals. Reproducibility and agreement were evaluated by intraclass correlation coefficients and Bland-Altman analyses. The effects of
cholecystectomy, age, and sex on BD diameter were analysed with linear mixed models.
Results: BD diameter inter-reader reproducibility and agreement were excellent at the level of the right hepatic artery (intraclass correlation
coefficient, 0.94). Sixty-one patients (21.0%) had a history of cholecystectomy. Among them, the 95th percentile of BD diameters at hepatic
artery level was 7.9 mm (<50 years) and 12.3 mm (
50 years). Among those without cholecystectomy, BD diameter was 6.2 mm (<50
years) and 7.7 mm (
50 years). Cholecystectomy was associated with significantly larger BD diameters in both age groups (P < .001). Older
age was associated with larger BD diameters (P .004). Sex had no impact on BD diameter (P .842).
Conclusion: Patients after cholecystectomy may present with an enlarged BD unrelated to cholestasis. The BD diameter increases with age.
Clinicians should rely on cholecystectomy status, age, and laboratory results to determine needs of further investigation.

R
esum
e

Objet: Evaluation r
etrospective de lincidence de la chol
ecystectomie, de l^age et du sexe sur le diametre du canal chol
edoque.
Mat
eriel et m
ethodes: De facon r
etrospective, nous avons r
evis
e les rapports de laboratoire et de tomodensitom
etrie abdominale a coupes
multiples avec contraste de 290 patients cons
ecutifs (119 hommes, ^age moyen de 55,9 ans) qui se sont pr
esent
es sans cholestase au service
durgence de notre
etablissement entre juin 2009 et ao^ut 2010. Le diametre du chol
edoque a
et
e mesur
e a trois endroits par deux observateurs
ind
ependants, deux fois a un mois dintervalle. La reproductibilit
e et la concordance ont
et
e
evalu
ees au moyen du coefficient de corr
elation
intraclasse et danalyses de Bland-Altman. Des modeles lin
eaires mixtes ont
et
e utilis
es pour analyser les effets de la chol
ecystectomie, de
l^age et du sexe sur le diametre du chol
edoque.
R
esultats: La reproductibilit
e et la concordance inter
evaluateur du diametre du chol
edoque
etaient excellentes au niveau de lartere
h
epatique droite (coefficient de corr
elation intercalaire de 0,94). Parmi les patients, 61 (21 %) pr
esentaient des ant
ec
edents de chol-

ecystectomie. Le 95e centile du diametre du canal chol
edoque au niveau de lartere h
epatique
etait de 7,9 mm (moins de 50 ans) et de
12,3 mm (50 ans ou plus) chez ces patients. Chez les patients qui navaient pas subi de chol
ecystectomie, le diametre du chol
edoque
etait de
6.2 mm (moins de 50 ans) et de 7,7 mm (50 ans ou plus). Des diametres nettement sup
erieurs pour les deux groupes d^age (P < 0,001)
etaient
associ
es a cette intervention. Les patients plus ^ag
es pr
esentaient des diametres plus grands (P 0,004). Le sexe navait aucune incidence sur
le diametre du canal chol
edoque (P 0,842).

* Address for correspondence: Jessica Murphy-Lavall
ee, MD, FRCPC, E-mail address: jessica.murphy-lavallee.chum@ssss.gouv.qc.ca (J.
Department of Medical Imaging, University of Montreal and CRCHUM, Murphy-Lavall
ee).
H^
opital Saint-Luc, 1058 rue Saint-Denis, Montr
eal, Qu
ebec H2X 3J4,
Canada.

0846-5371/$ - see front matter 2013 Canadian Association of Radiologists. All rights reserved.
http://dx.doi.org/10.1016/j.carj.2012.09.004
2 D. Landry et al. / Canadian Association of Radiologists Journal xx (2013) 1e6
Conclusion: Le chol
edoque des patients qui ont subi une chol
ecystectomie peut ^etre plus large sans quil ny ait de lien avec une cholestase.
Le diametre augmente toutefois avec l^age. Les cliniciens devraient se fier a l
etat de la chol
ecystectomie, a l^age et aux r
esultats de lab-
oratoire pour d
eterminer si une investigation plus pouss
ee est n
ecessaire.
2013 Canadian Association of Radiologists. All rights reserved.
Key Words: Bile duct; Cholecystectomy; Cholestasis; Dilatation
It is a widely accepted concept that the bile duct (BD)
increases in diameter after cholecystectomy. However, there is
little consensus in the available literature on this subject. The
opinion dates back to the late 19th century, when Oddi [1]
postulated that the choledochus dilates after removal of the
gallbladder to serve as a reservoir for bile [2]. This phenom-
enon was explained by the hypothesis that one function of the
gallbladder is to act as a tension bulb to maintain stable bile
pressure when the sphincter of Oddi is closed [3]. Hence, once
removed, the pressure gradients would be applied directly to
the BD, which would dilate in response. Subsequent research
on animals and postmortem studies on humans seemed to
validate this hypothesis [2e5]. However, the advent of sono-
graphic technology and subsequent analyses of the biliary tree
in the mid-20th century provided inconsistent and often
contradictory evidence [4,6e14].
Radiologists can be confronted with unanticipated dilated
extrahepatic BDs in patients in whom the necessity for further
cholestatic investigation is unclear. Hence, knowing whether it
is expected that patients who had a cholecystectomy, who do
not present with cholestasis, have more prominent extrahe-
patic BDs than the general population would be of value and
help prevent unnecessary further, potentially invasive and
costly, investigation of the biliary system.
The purpose of this study was to retrospectively assess the
impact of cholecystectomy status, age, and sex on the BD
diameter by measuring the BD diameter in patients who
underwent an abdominal multidetector computed tomog-
raphy (MDCT) for reasons unrelated to cholestasis.
Materials and Methods
Our institutional review board approved this retrospective
study and waived the need for informed consent.
Study Population
We reviewed the laboratory results and contrast-enhanced
MDCT images of 290 consecutive patients admitted to the
emergency department of a tertiary care university-affiliated
hospital between June 2009 and August 2010. A systematic
electronic chart review for each patient was conducted.
Patients were included if they were (a) 18 years old or older,
(b) had a contrast-enhanced abdomen MDCT, (c) presented
with symptoms unrelated to cholestasis (eg, appendicitis
workup, suspected diverticulitis, suspected occlusion or sub-
occlusion, epigastric discomfort, vague abdominal pain), (d)
had proven absence of cholestasis by normal laboratory values
of both total blood bilirubin level (reference range, 7-23 mmol/
L) and blood levels of alkaline phosphatase (reference range,
36-110 IU), obtained within 24 hours of the contrast-enhanced
MDCT. Patients were not included if they had proven liver or
pancreatic malignancy or disease. Patients chronically taking
opioid medication and those who had received morphine
before the computed tomography (CT) were also excluded. A
total of 354 patients were initially recruited, of whom, 29 had
liver cancer, 6 had pancreatic cancer, 5 had a biliary stent, 10
had cholecystitis, 4 had liver transplantations, 2 had benefited
from a Whipple surgery, and 8 had received morphine before
imaging. Thus, these 64 patients were excluded.
Scanning Technique
Abdominal CT studies were performed on 64-row
detector MDCT scanners (Philips Brillance 64 [Philips
Healthcare, Celveland, OH]; Somatom Sensation 64
[Siemens Healthcare, Forchheim, Germany]). The single
portal venous-phase protocol consisted of images of the
abdomen and pelvis acquired by using a 2.5-mm collimation
70 seconds after intravenous injection of a bolus of 100 mL
iohexol contrast medium (Omnipaque 300; Bracco, Milan,
Italy) with a power injector at a rate of 3.0 mL/s.
Image Evaluation
The diameters of the extrahepatic BD were measured at 3
distinct locations: immediately superior to the pancreas
(dpancreas), adjacent to the right hepatic artery (dartery), and
immediately below the first hepatic hilar bifurcation (dbifurc)
(Figure 1). To minimize interobserver variations, all mea-
surements were taken only on axial images, perpendicular to
the cephalocaudal direction of the BD. The measurements
were performed independently by a radiology resident in his
fourth year of training (reader A [D.L.]) and a fellowship-
trained body-imaging radiologist with 6 years of experience
(reader B [J.M.L.]) by using our picture archiving and
communication system (AGFA Impax ES; AGFA Technical
Imaging Systems, Ridgefield Park, NJ). Both readers took the
measurements twice, at a 1-month interval and were blinded to
their previous reported values as well as the values taken by their
colleague. This permitted us to evaluate inter- and intrareader
reproducibility and agreement.
Statistical Analyses
Quantitative variables were summarized as means (stan-
dard deviations [SD]), and categorical variables were
 Bile duct diameter and cholecystectomy / Canadian Association of Radiologists Journal xx (2013) 1e6 3

Figure 1. Transverse portal venous phase 64-row computed tomography image of a 75-year-old male patient who presented with right hydronephrosis caused
by a ureteral lithiasis. The bile duct diameter (arrows) was measured at the level of the pancreas (dpancreas) (A), at the crossing of the hepatic artery (dartery) (B),
and below the first hepatic hilar bifurcation (dbifurc) (C).

summarized as proportions and percentages. The sample size
of 290 patients was calculated to be able to detect a 1-mm
difference in BD diameter with a power of .98 and a type I
error (alpha) of .01. Because previous studies reported an
average prevalence for cholecystectomy of 25% (with an SD
of 1.67% reported in 1 study) [15e19], a total of 290 patients
was necessary, with 62 patients after cholecystectomy and
228 controls (by using t test for unequal samples, non-
matched pairs [20]).
Inter- and intrareader reproducibilities were assessed
by intraclass correlation coefficients (ICC). Because the
subjects and readers of our study were randomly chosen from
a bigger pool of individuals, a 2-way underlying analysis of
variance model was used [21]. An ICC value greater than
0.75 was interpreted as excellent reproducibility, values of
0.40-0.75 as fair to good reproducibility, and values of <0.40
as poor reproducibility [22]. Agreement between the 2
readers regarding the BD diameters was assessed by Bland-
Altman analysis to compute the limits of agreement [23,24].
Significance was set at P < .05 for all tests. All statistical
analyses were performed by using statistical software
(R version 2.13.0 for Windows, Vienna, Austria; and pack-
ages irr v.0.83 and nlme 3.1-102 [25,26]). The effects of
cholecystectomy, age (dichotomized as <50 years of age and

50 years of age), and sex on BD diameter were analysed
with linear mixed model analysis. This alllowed us to
account for the repeated measurements by the 2 readers as
well as the effect of other potential covariates.
Results
ICCs of inter- and intrareader reproducibility are summa-
rized in Tables 2 and 3, respectively.
Inter-reader Agreement
Bland-Altman graphs were obtained for measurements at
each location (Figure 2) and revealed agreement only at the
level of the right hepatic artery. Indeed, there were only
93.4% and 91.4% of the differences contained within the
limits of agreements at the suprapancreatic and hepatic
bifurcation levels, respectively. Further, when accepting
a maximum difference of 2.0 mm between each readers
measurements to be within boundaries of agreement, agree-
ment was also obtained only at the level of the hepatic artery.
Summarized in Table 4 are the averages of differences in
measurements obtained by the 2 readers and the interval that
contains 95% (2 SDs) of the differences in measurements.
The results obtained at the level of the intrahepatic bifurca-
tion yielded an average difference in measurements of
1.1 mm, with a 95% confidence interval excluding zero.
Effect of Cholecystectomy, Age, and Sex
Because Bland-Altman analysis of the measurements
between the 2 readers demonstrated that agreement was only
achieved at the level of the right hepatic artery, this level was
selected to evaluate variations in BD diameters. There was
a statistically significant increase in BD diameters in patients
with a history of cholecystectomy; on average, BD diameter
was 2.3 mm larger when compared with patients without

Study Population Table 1

Population demographics
A total of 290 patients (119 men; mean [SD] age, 55.9  Postcholecystectomy No cholecystectomy
14.5 years [range, 30-80 years]) comprised our results. Sixty- (n 61) (n 229)
one patients (21.0%) previously underwent cholecystectomy. Clinical
The demographics for each group are summarized in Table 1. Mean age (years), SD 64  12.5 54  14.3
Men, no. (%) 17 (28) 102 (45)
Laboratory
Inter- and Intrareader Reproducibility Total bilirubin level, 9.6  3.9 10.5  7.9
mmol/L
The inter- and intrareader reproducibility of BD diameter Alkaline phosphatase 77  16.1 68  21.7
measurements was excellent at the suprapancreatic and level, IU/L
hepatic artery levels, and good at the bifurcation level. The SD standard deviation.
4 D. Landry et al. / Canadian Association of Radiologists Journal xx (2013) 1e6
Table 2
Inter-reader reproducibility
Measurement level Suprapancreatic Hepatic artery Bifurcation
ICC 0.90 0.94 0.70
95% CI 0.87-0.92 0.92-0.95 0.07 to 0.87
P value <.001 <.001 .034
CI confidence interval; ICC intraclass correlation coefficients.
cholecystectomy (P < .001). A statistically significant
increase in BD diameters with increasing age was also found
(P .004) (Figure 3). A history of cholecystectomy was
associated with increased BD diameters, regardless of patient
age (P < .001). Among patients with a history of cholecys-
tectomy, the 95th percentile of BD diameters at the hepatic
artery level was 7.9 mm (<50 years) and 12.3 mm (
50
years); among those without a history of cholecystectomy, it
was 6.2 mm (<50 years) and 7.7 mm (
50 years). Sex was
not found to be associated with statistically significant vari-
ations on BD diameter at any of the 3 levels investigated
(P .842). The effect of covariates on BD diameters are
summarized in Table 5.
Discussion
It is widely accepted among radiologists that the extrahe-
patic BD dilates after cholecystectomy. However, the literature
offers little consensus in this regard. We conducted our study to
investigate if cholecystectomy status, age, and sex had
measurable impacts on the diameter of the extrahepatic BD.
Most studies to date have investigated BD diameters in patients
planned to undergo cholecystectomy for cholecystitis
[7,8,10,11,13,27,28]. This approach suffers from selection
bias and cannot show if the effects on the BD diameter result
from cholecystectomy or the underlying obstruction of the BD.
Furthermore, in everyday practice, the question is not whether
the BD has dilated after cholecystectomy; the most pertinent
information is to know whether it is expected that patients who
had a cholecystectomy who do not present with cholestasis
have more prominent extrahepatic BDs than the general pop-
ulation. Indeed, the radiologist is often confronted with
unanticipated extrahepatic BDs of generous calibre on
abdominal computed tomodensitometry or abdominal ultra-
sound (US) performed for reasons unrelated to cholestasis or
biliary pathology in the absence of cholestasis (proven clini-
cally and paraclinically). Knowing that a higher percentage of
patients who benefited from cholecystectomy will have
prominent extrahepatic BDs without underlying biliary
pathology would reassure both the radiologist and the
Table 3
Intrareader reproducibility
Reader A
Measurement level Suprapancreatic Hepatic artery
ICC 0.97 1.00
95% CI 0.96-0.97 0.99-1.00
P value <.001 <.001
CI confidence interval; ICC intraclass correlation coefficient.
clinician, and prevent unnecessary further, potentially invasive
and costly, investigation of the biliary system.
The interest in demonstrating an impact of the diameter of
extrahepatic BDs in patients with a history of cholecystectomy
has been present for many decades. In 1957, Anderson [6]
published the results of a study conducted on 125 patients,
with and without a history of cholecystectomy, who had an
intravenous cholecystography. Although technical difficulties
were encountered in some patients, he raised doubts on the
long-held belief that the extrahepatic BD dilates after gall-
bladder removal. Subsequently, Mueller et al [9] conducted
one of the first US studies on the common BD diameter in 40
patients before and after cholecystectomy for up to 20 months
after surgery. Of these patients, only 1 patient presented with
persistent dilatation of the common BD. The patient was 85
years old, and the BD dilatation was attributed to physiologic
senile loss of muscular tone of the duct. The remaining
patients maintained or recovered normal-size BDs. Later on,
many researchers reported similar findings when using US for
evaluation of the biliary tree.
Recently, Chawla et al [14] analysed common BD diam-
eter on chest computer tomodensitometry in patients who
presented for unrelated reasons and without cholestasis
(either clinically or via laboratory findings). They reported
a series of 40 matched pairs and found that significant
dilatation of the common BD was associated with prior
cholecystectomy. A review of the literature conducted in
1997 concluded that, although there is no consensus in the
scientific community, literary evidence suggests that BD
dilatation occurs in a majority of patients with a history of
cholecystectomy [12].
In our study, a history of cholecystectomy was indeed
associated with larger BD diameters in patients without
cholestasis. Measurements of the BD at 3 distinct locations by
2 readers on separate occasions provided our study with the
possibility to evaluate reproducibility as well as agreement
within each reader and between them. Analysis with ICCs
showed that reproducibility of measurements obtained by each
reader was best at the level where the BD crosses the right
hepatic artery. Further investigation by using Bland-Altman
graphs demonstrated that agreement was only reached at this
level. This observation is explained by the fact that the precise
location for measurement of the BD is achieved only at
a location that can be precisely identified by both readers.
Because the BD crosses the path of the right hepatic artery at
almost 90 degrees, it yields a very unique point where the
diameter can be obtained reliably. This is the classically rec-
ommended level to measure the BD, both on US and CTs. Our
Reader B
Bifurcation Suprapancreatic Hepatic artery Bifurcation
0.92 0.94 0.98 0.83
0.90-0.94 0.93-0.95 0.97-0.98 0.79-0.87
<.001 <.001 <.001 <.001
 Bile duct diameter and cholecystectomy / Canadian Association of Radiologists Journal xx (2013) 1e6 5

Table 4
Mean of differences in measurements between readers
Measurement level Suprapancreatic Hepatic artery Bifurcation
Mean, mm 0.14 0.05 1.01
95% CI for the mean 0.01-0.28 0.15 to 0.06 0.90-1.13
difference, mm
Limits of agreement 2.3 to 2.6 1.9 to 1.8 1.2 to 3.2
CI confidence interval.

[6,9,12,14,29e33]. There was no effect of sex on the BD

diameter in our population, similar to previous studies [9,14].
Contrary to many previous studies, our study did not
attempt to determine if the extrahepatic BDs dilate in a given
patient after cholecystectomy. Such a study would be quite
difficult to conduct because patients who initially benefit from
imaging of the BDs in these instances could have some degree
of BD obstruction, hence the need for cholecystectomy. As
a result, the causality link between cholecystectomy and
dilated BDs is polluted by the possibility that BDs were
already dilated at presentation because of the initial pathology.
Indeed, in a few studies [6,8], some patients who were
recruited initially had BD diameters that fell within the normal
range and did not show an increase in calibre after cholecys-
tectomy. However, in other studies [9,10], the patients initially
presented with increased BD diameter. In everyday practice,
the radiologist does not need to know whether a patient will
eventually have dilated BDs after cholecystectomy. Rather, the
imaging specialist is often confronted with dilated extrahe-
patic BDs in a patient who already has benefited from chole-
cystectomy. As our study has shown, a greater proportion of
patients with a history of cholecystectomy will possess dilated
extrahepatic BDs with no cholestasis and should thus not be
investigated further regarding this finding.
There are several limitations to our study. First, the retro-
spective design of this study is prone to selection bias. However,
given that our data were based on consecutive patients, this
reflects the patient population at our institution. Second, we have
not included patients who presented with cholestasis, nor did we
include patients who had not benefited from laboratory workup
shortly before or after imaging to prove absence of cholestasis.

Figure 2. Bland-Altman plots, showing the mean difference between readers

A and B, and limits of agreement (95% confidence interval, dotted lines) for
the bile duct diameter at the (A) suprapancreatic, (B) hepatic artery, and (C)
intrahepatic bifurcation levels.

study reinforces the importance of measuring the BD at this

level to ensure reproducibility and consistency in measure-
ments obtained by different readers.
Measurements of the BD at the level of the right hepatic
artery showed that, at all ages, patients with a history of
cholecystectomy had statistically significant larger diame-
ters. Furthermore, regardless of cholecystectomy status, Figure 3. A scatter plot of bile duct diameters at the right hepatic artery
increasing age was associated with increased BD diameter. plotted by age; a 95th percentile curve fit is plotted for postcholecystectomy
These observations are consistent with many previous studies and noncholecystectomy status.
6 D. Landry et al. / Canadian Association of Radiologists Journal xx (2013) 1e6
Table 5
Average diameters at level of hepatic arterya
Cholecystectomy Yes
All 7.1  2.4; (2.4, 11.8) mm
Age <50 years
All 4.5  1.0; (2.5, 6.5) mm
Cholecystectomy 6.1  0.9; (4.3, 7.9) mm
No cholecystectomy 4.3  0.9; (2.5, 6.1) mm
Sex Women
All 5.2  1.9; (1.5, 8.9) mm
Cholecystectomy 7.1  2.4; (2.4, 11.8) mm
No cholecystectomy 4.6  1.2; (2.2, 7.0) mm
SD standard deviation.
a
Results are reported as: result  repeatability coefficient (1.96 SD); (95% limits of agreement interval).
However, our goal was precisely to describe the BD diameter of
patients in whom the benefit of further investigation was unclear.
Third, it was not possible to produce a blinded study because the
cholecystectomy status was evident to the readers. However,
prior knowledge of cholecystectomy status mirrors clinical
conditions; furthermore, comparable results for both readers
suggest that their results were in good agreement, if not unbiased.
In conclusion, reproducible diameters were obtained
where the hepatic duct crosses the right hepatic artery.
Patients after cholecystectomy may present enlarged BDs
unrelated to cholestasis, and hepatic duct diameter increases
with age regardless of cholestasis. Hence, clinicians should
rely on cholecystectomy status, age, and laboratory results to
determine the need for further investigation.
References
[1] Oddi R. Sulla esistenza di speciali gangli nervosi in prossimita dello
sfintere del coledoco. Monitore Aoologico Italiano 1894;5:216e7.
[2] Judd E, Mann F. The effect of removal of the gall-bladder. Surg Gynec
Obstet 1917;24:437e42.
[3] Judd E. Condition of the common duct after cholecystectomy. JAMA
1923;81:704e8.
[4] Mahour G, Wakim K, Ferris D, et al. Canine common bile duct: chronologic
changes in caliber after cholecystectomy. Arch Surg 1969;98:239e40.
[5] Puestow C, Morrison R. The relationship of cholecystitis and
cholecystectomy to dilation of the choledochus. Ann Surg 1935;101:
599e601.
[6] Anderson F. The biliary tract in the normal and cholecystecomized
patient. AJR Am J Roentgenol 1957;78:623e31.
[7] Gylstorff H, Faber H. Choledochus changes after cholecystectomy.
Acta Chir Scand 1963;125:499e501.
[8] Edmunds R, Katz S, Garciano V, Finby N. The common duct after
cholecystectomy. Arch Surg 1971;103:79e80.
[9] Mueller P, Ferrucci Jr J, Simeone J. Postcholecystectomy bile duct
dilation: myth or reality? AJR Roentgenol 1981;136:355e8.
[10] Graham M, Cooperberg P, Cohen M, et al. The size of the normal
common hepatic duct following cholecystectomy: an ultrasonographic
study. Radiology 1980;135:137e9.
[11] Feng B, Song Q. Does the common bile duct dilate after cholecys-
tectomy? Sonographic evaluation in 234 patients. AJR Roentgenol
1995;165:859e61.
[12] Hammarstr om L-E. Is there a significant increase in bile duct width
after cholecystectomy? Scand J Gastroenterol 1997;32:961e4.
[13] Majeed A, Ross B, Johnson A. The preoperatively normal bile duct
does not dilate after cholecystectomy: results of a five year study. Gut
1999;45:741e3.
No
P < .001 4.8  1.2; (2.4, 7.2) mm P < 0.001

50 years
P .004 5.1  2.1; (1.0, 9.2) mm P .004
P < .001 7.3  2.5; (2.4, 12.2) mm P < .001
P < .001 4.8  1.4; (2.1, 7.5) mm P < .001
Men
P .842 4.9  1.8; (1.4, 8.4) mm P .842
P < .001 7.2  2.5; (2.3, 12.1) mm P < .001
P < .001 4.6  2.7; (1.9, 7.3) mm P < .001
[14] Chawla S, Trick W, Gilkey S, et al. Does cholecystectomy status
influence the common bile duct diameter? A matched-pair analysis.
Dig Dis Sci 2010;55:1155e60.
[15] Buanes T, Mjaland O, Adamsen S. A population-based survey of
biliary surgery in Norway. Relationship between patient volume and
quality of surgical treatment. Surg Endosc 1998;12:1386e9.
[16] Attili A, Carulli N, Roda E, et al. Epidemiology of gallstone disease in
Italy: prevalence data of the Multicenter Italian Study on Cholelithiasis
(M.I.COL.). Am J Epidemiol 1995;141:158e66.
[17] Muhrbeck O, Ahlberg J. Prevalence of gallstone disease in a Swedish
population. Scand J Gastroenterol 1995;30:1125e8.
[18] Pixley F, Wilson D, McPherson K, et al. Effect of vegetarianism on
development of gall stones in women. Br Med J 1958;291:291e311.
[19] Sturdevant R, Pearce M, Dayton S. Increased prevalence of choleli-
thiasis in men ingesting a serum-cholesterol-lowering diet. N Engl J
Med 1973;288:24e7.
[20] Dupont WD, Plummer WD. PS: Power and Sample Size Calculations,
Version 3.0; 2009. Available at: http://biostat.mc.vanderbilt.edu/wiki/
Main/PowerSampleSize. Accessed December 2, 2010.
[21] Shrout P, Fleiss J. Intraclass correlations: uses in assessing rater reli-
ability. Psychol Bull 1979;86:420e8.
[22] Rosner B. Fundamentals of Biostatistics. Boston, MA: Duxbury Press;
2006.
[23] Bland J, Altman D. Statistical methods for assessing agreement
between two methods of clinical measurement. Lancet 1986;I:307e11.
[24] Bland J, Altman D. Applying the right statistics: analyses of
measurement studies. Ultrasound Obstet Gynecol 2003;22:85e93.
[25] Gamer M, Lemon J, Singh IFP. irr: Various Coefficients of Interrater
Reliability and Agreement. 0.83 ed: R package; 2010. Available at
http://cran.r-project.org/web/packages/irr/irr.pdf. Accessed December
2, 2010.
[26] Pinheiro J, Bates D, DebRoy S, et al. nlme: Linear and Nonlinear Mixed
Effects Models. 3.1e102 ed: R package; 2011. Available at http://cran.r-
project.org/web/packages/nlme/nlme.pdf. Accessed December 2, 2010.
[27] Bruneton J-N, Roux P, Fenart D. Ultrasound evaluation of common bile
duct size in normal adult patients and following cholecystectomy.
Europ J Radiol 1981;1:171e2.
[28] Morgan B, Rathod A, Crozier A, et al. Biliary distensibility during per-
operative cholangiography as compared to pre-operative ultrasound:
a four year follow-up study. Clin Radiol 1996;51:338e40.
[29] Mahour G, Wakim K, Ferris D. The common bile duct in man: its
diameter and circumference. Ann Surg 1967;165:415e9.
[30] Wu C-C, Ho Y-H, Chen C-Y. Effect of aging on common bile duct
diameter: a real-time ultrasonographic study. J Clin Ultrasound 1984;
12:473e8.
[31] Perret R, Sloop G, Borne J. Common bile duct measurements in an
elderly population. J Ultrasound Med 2000;19:727e30.
[32] Bachar G, Cohen M, Belenky A. Effect of aging on the adult extra-
hepatic bile duct. J Ultrasound Med 2003;22:879e83.
[33] Oarulekar S. Ultrasound evaluation of common bile duct size.
Radiology 1979;133:703e7.