CURRENT REVIEWS IN GASTROINTESTINAL, MINIMALLY INVASIVE, & ENDOCRINE SURGERY

CholedocholithiasisPrinciples of Diagnosis and Management

Brian E. Lahmann, MD,* Gina Adrales, MD,* and Richard W. Schwartz, MD* *Department of Surgery, University of Kentucky College of Medicine and Veterans Administration Hospital, Lexington, Kentucky
Cholelithiasis is commonly encountered in surgical practice, with gallstones present in 10% to 20% of the adult population. The indications for cholecystectomy have been reviewed previously in this series.1 Between 4% and 15% of patients undergoing laparoscopic cholecystectomy will be found to have 1 or more stones in the common bile duct (CBD) or choledocholithiasis (CDL).2,3 There are several important clinical ramications in the diagnosis and management of CDL, and this manuscript serves to delineate the current relevant concepts. wall. The ducts concomitantly dilate and thicken, with migration and proliferation of inammatory cells. Because the resultant clinical manifestations vary, CBD stones may remain asymptomatic for years. The patient with CDL often complains of colicky right upper quadrant abdominal pain and intermittent jaundice. If obstruction of biliary outow is complete, jaundice progresses and is persistent. Common symptoms include pale stools and dark-colored urine, which can be elicited by a thorough review of systems. Serum laboratory values are valuable in assessing the patient with CDL. Alkaline phosphatase is elevated early in the disease process, as is the total bilirubin. These 2 values, in addition to lactate dehydrogenase and AST are cumulative in predicting the patient with CDL. If 1 of these 4 values is elevated, then the patient has a 20% likelihood of having a CBD stone. Two abnormal levels increase this percentage to 40%, and 3 abnormalities increase the likelihood of CDL to greater than 50%.2,3 However, transaminases, including AST, are often normal. Prothrombin time may be elevated, as Vitamin K absorption depends on bile acids entering the gastrointestinal tract. Two serious complications of CDL are cholangitis and gallstone pancreatitis. Cholangitis is a suppurative infection of the biliary tree and may ascend into the liver, causing abscess. Cultures are most often positive for E. coli, and the infection clears with antibiotics in more than 75% of cases.2 In cholangitis, the classic description of Charcots triad is often encountered, consisting of fever, right upper quadrant pain, and jaundice. The less common Reynolds pentad adds the elements of systemic shock and mental status changes.2,3 In cholangitis, the white blood cell count will certainly be elevated in an immunocompetent patient. Amylase and lipase levels will rise in gallstone pancreatitis.2,3 Gallstone pancreatitis is an indication for cholecystectomy during the same hospital admission. At operation, the pancreas may be observed to be normal, edematous, or frankly necrotic.2,3

PATHOGENESIS
Biliary stones result from an imbalance among cholesterol, bile salts, and lecithin. In the European and North American populations, these are often called cholesterol stones, as they consist of more than 60% cholesterol. Primary CBD stones are formed within the ducts themselves, whereas secondary stones pass from the gallbladder via the cystic duct. Most biliary stones fall into the latter category; 95% of those with choledocholithiasis also have stones in the gallbladder. Secondary stones are associated with long-standing cholelithiasis, so that an enlarged cystic duct facilitates passage of multiple small stones into the common duct. Primary stones are different entities, having a brownish color and mud-like, friable texture. They are associated with biliary stasis and infection, as well as with abnormalities of the Sphincter of Oddi. It is important to distinguish between primary and secondary stones; whereas cholecystectomy and choledocholithotomy are sufcient in the management of secondary stones, the presence of primary stones often necessitates a more complex drainage procedure to prevent recurrence.2-4

CLINICAL MANIFESTATIONS
If stones in the biliary tree are small enough, they may pass into the duodenum. However, the distal duct is only 2 to 3 mm in diameter, so stones exceeding this size can obstruct biliary outow, which leads to edema, spasm, and brosis of the ductal
Correspondence: Inquiries to Richard W. Schwartz, MD, Surgery Publications, MN258, UK College of Medicine, 800 Rose Street, Lexington, Kentucky 40536-0298; fax: (859) 257-8934; e-mail: rschw01@uky.edu

DIAGNOSIS
Patients exhibiting the symptoms above require diagnostic investigation to assess the presence of CDL. Cholangiography is
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CURRENT SURGERY 2004 by the Association of Program Directors in Surgery Published by Elsevier Inc.

the criterion standard, including intraoperative cholangiography and endoscopic retrograde cholangiopancreatography (ERCP). These studies give real-time assessment of bile duct patency as well as other anatomic information. Intraoperative cholangiography can be performed under uoroscopy, and it has been proposed by some surgeons to be performed during every laparoscopic cholecystectomy. Intravenous glucagon may assist in visualizing the entire biliary tree.3,5 Abdominal ultrasound is very sensitive in detecting cholelithiasis, but it often cannot visualize stones in the common bile duct. Extrahepatic ductal dilatation ( 10 mm) can sometimes be identied, as well as echogenic foci in the common bile duct. Overall, ultrasound is only up to 80% accurate in diagnosing CDL. Therefore, an ultrasound interpreted as normal may be misleading as to the presence of CBD stones.3,5 Endoscopic retrograde cholangiopancreatograph conrms the diagnosis of CDL as well as the location of the stone. This procedure was initially employed in diagnosis, but today is most often used as a therapeutic measure. Cholangiography remains the criterion standard in diagnosing CBD stones; sensitivity is up to 95%, and specicity is 92% to 98%.2,6,7 Percutaneous transhepatic cholangiography (PTC) involves passing a guidewire through the liver parenchyma into the biliary tree to make a diagnosis. Although it permits interventions, PTC is usually inferior to ERCP in extracting stones, as it necessitates the pushing of stones into the duodenum as opposed to pulling them through the ampulla as with ERCP. The procedure is traumatic, with bleeding being the main complication.6,7 Endoscopic ultrasound is signicantly more sensitive than transabdominal ultrasound in diagnosing CDL. Its sensitivity is the same as diagnostic ERCP (97%), and its major advantage is decreased morbidity as compared with ERCP.8 Laparoscopic intracorporeal ultrasound is performed at the time of laparoscopic cholecystectomy, and it is faster and more sensitive than cholangiography. The benets of this procedure include avoidance of both cystic duct cannulation and ionizing radiation exposure.3,9 Magnetic resonance cholangiography is a new noninvasive technology that is accurate in diagnosing CDL. This may prove benecial in identifying patients who would benet from early intervention.10-12 Helical CT (tomographic IV cholangiography) is another new technique, with excellent visualization of the biliary anatomy and lling defects (95% sensitive for diagnosing CDL).13

TREATMENT
Patients with cholangitis or gallstone pancreatitis are acutely ill, and they often require aggressive rehydration. Antibiotics are indicated if infection is present, and complete bowel rest (NPO, nasogastric intubation) may be necessary. The patient may require correction of coagulopathy, especially when an intervention is planned.3 The management of CDL and its resultant complications is
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mostly interventional, but there are some nonoperative forms of management that may be appropriate in selected patients. These include oral dissolution therapy (Ursodiol, Actigall), contact dissolution therapy, and extracorporeal shock wave lithotripsy. As a group, these methods may benet a patient who cannot undergo surgery and may work best on solitary stones less than 2 cm in diameter. These treatments are now considered adjuncts to surgery rather than alternatives. Overall, results are poor compared with the interventions described below.2,14,15 Two groups of interventions have signicant roles in managing CDL: ERCP and CBD exploration. Endoscopic retrograde cholangiopancreatograph can be used as the sole treatment for CDL, but it is most useful as an adjunct to surgery (either open or laparoscopic cholecystectomy).3 Several manipulations can be performed through the side-viewing duodenoscope in addition to cannulating and imaging the biliary tree. These include endoscopic sphincterotomy (ES), endoscopic balloon dilation, stent placement, and mechanical lithotripsy. Sphincterotomy is the most successful in this setting, as the destruction of Oddis sphincter allows the passage of residual material in the bile ducts.2,3,6,16,17 Some surgeons will elect to obtain ERCP before a planned laparoscopic cholecystectomy if CBD stones are detected by preoperative studies. Preoperative ERCP with ES clears the common duct of stones in most cases. Other indications for ERCP include persistent jaundice, suspicion of malignancy, ascending cholangitis, and pancreatitis. Patients with residual stones after cholecystectomy also benet from ERCP. Yet complications are not infrequent, with a rate approaching 10%, and include pancreatitis, infection, bleeding, and perforation. The procedure also may fail in removing the stones, prompting operative intervention.3,6,18 Operative management of CDL consists of choledocholithotomy (CBD exploration and stone retrieval) and biliary drainage procedures. The latter consists mainly of choledochoduodenostomy and Roux-en-Y choledochojejunostomy. Some authors have proposed these 1-stage operations as superior in outcome and cost efciency as compared with multiple interventions (laparoscopic cholecystectomy, ERCP, etc.)2,3 Both open and laparoscopic approaches are viable options; the laparoscopic operations are discussed separately, in the companion article. The indications for CBD exploration are the same as those for ERCP, with the addition of discovery of stones at operation (by palpation or cholangiogram). Exposure is the same as for standard cholecystectomy, via right subcostal incision. Stay sutures are placed in the CBD just distal to the cystic duct; this site is chosen to facilitate choledochoduodenostomy should it be required. The CBD is opened longitudinally with #11 scalpel, approximately 1.5 cm in length. Stone forceps or balloon catheters are then introduced for stone extraction. Additionally, a stiff urologic catheter may be introduced and passed into the duodenum. Normal saline is injected as the catheter is withdrawn, ushing and dislodging the stones. Rigid or exible
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choledochoscopy may be performed as both a diagnostic and therapeutic maneuver.3,16 The duodenum must be mobilized (Kochers maneuver) if simple interventions are unsuccessful. This facilitates the safe manipulation of the distal bile duct as well as passage of catheters past the ampulla. Open sphincterotomy is rarely necessary, but it may help if a stone is rmly lodged in the duct. A longitudinal duodenotomy is made at the level of the ampulla, 5 to 6 cm in length. With a dilator stenting opening the ampulla, 4-0 silk stay sutures are placed, and the sphincter is incised with #11 blade. The stone is then extracted, and the duodenum is closed longitudinally with 3-0 silk. T-tube choledochostomy should be performed in the absence of a sphincterotomy. This tube serves to stent the closure and provides a diagnostic tool in managing the patient postoperatively. A straight path as the tube traverses the abdominal wall is vital to facilitate the instrumentation of the tract if necessary. The tube should be at least 14 French, and it is secured with absorbable suture, with care taken not to incorporate ductal mucosa in the sutures. Saline is injected to assess the closure for gross leakage. Cholangiogram is performed before closure, giving a baseline for comparison to later images.3,16 A closed drain is placed and exited through a separate incision. The T-tube is left in place for at least 4 weeks, when another cholangiogram is performed. Five percent to 15% of those who have undergone open CBD exploration will show retained stones on this study. This presents a diagnostic dilemma with several possible therapeutic options. These include (1) observation, (2) ERCP, (3) extraction, (4) dissolution, and (5) re-exploration. The stones may simply be observed, as small stones often pass in less than 8 weeks. Passage of a proximal stone may necessitate the removal of the T-tube, as it may obstruct the stones path past the ampulla. Endoscopic retrograde cholangiopancreatograph with sphincterotomy is often employed in these patients, with good results. The T-tubes tract is relatively mature at 6 to 8 weeks, and it may be removed over a guidewire. Stone baskets can then be introduced into the duct under uoroscopy, with very good rates of extraction. Choledochoscopy can be performed through the dilated tract, which may facilitate stone extraction.19 Dissolution is only successful with cholesterol stones. Multiple solutions have been proposed, including heparin and monooctanoin, with variable results. Lastly, if there are many stones in the CBD along with ampullary stenosis, the patient may benet from reoperation and conversion to choledochojejunostomy or choledochoduodenostomy.2,16 Choledochoduodenostomy is the most commonly performed drainage procedure, and it is proposed by some surgeons as part of the initial operation. This avoids T-tube drainage as well as subsequent cholangiograms and possible interventions. The anastomosis can be end-to-side or side-toside, along the antimesenteric border of the duodenum. However, this reconstruction can lead to cholangitis and sump syndrome, resulting from reux into the biliary tree. These problems are largely avoided with Roux-en-Y choledochojeju292

nostomy. In either reconstruction, the anastomosis should be 2 to 2.5 cm long, and it is safely performed in a single layer.3 Postoperatively, the patient may require nasogastric drainage, but often the patients can be fed on postoperative day #1. Possible complications of the operation include bile leak, abscess, CBD injury, pancreatitis, and cholangitis.

OUTCOMES
The presence of CDL alone adds only minimal morbidity and mortality to the patient undergoing cholecystectomy for gallstones. In fact, open choledochostomy at the time of cholecystectomy adds only 1% overall mortality.2 In contrast, the complications of cholangitis and pancreatitis add signicant morbidity and mortality to the natural history of cholelithiasis. Surgical and endoscopic management of these problems have similar outcomes in short- and long-term follow-up. Elderly patients and those with signicant medical comorbidities may be better served by endoscopic treatment, possibly including nasobiliary drainage. The key to a good outcome via either modality is early intervention.20-22 In summary, CDL presents a challenging clinical dilemma to the practicing surgeon. With a careful history, physical examination, and diagnostic evaluation, the optimal management can be readily ascertained.

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