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CHOLEDOCHOLITHIASIS: DIAGNOSIS AND TREATMENT




B Millat, MD, Hôpital Saint Éloi, Montpellier, France
B Malassagne, MD, PhD Hôpital Henri Mondor, Université Paris XII, Créteil, France





1. Introduction

2. Preoperative detection

3. Intraoperative detection

4. Treatment

5. References


1. Introduction

Surgical treatment of choledocholithiasis (CL) takes into account the confluence of the bile ducts including the gallbladder, the cystic duct and the common bile duct (CBD), and the pathophysiology of stone disease, i.e. gallstones and common duct stones are the same disease.
Figure
Figure 1.a

The treatment thus involves the mobilization of human and technical means: a team, an operation. Cholecystectomy is the treatment for symptomatic gallstones. Intraoperative cholangiography (IOC) is the reference examination for diagnosis of CL; its results determine whether CBD exploration is advisable.
The goals of this article are:
  • to assess the means of diagnosis;
  • to assess the means of treatment of CBD stones;
  • to study respective indications of laparoscopic CBD exploration (LCBDE) and endoscopic sphincterotomy (ES).
Figure
Figure 1.b

1.1. What is the prevalence of CBD stones?

Choledocholithiasis is found in approximately 10-20% of patients who undergo open cholecystectomies (OC) ( Madden, 1973; National Institutes of Health, 1993; McSherry and Glenn, 1980; Coelho et al., 1984 ).
In the era of laparoscopic cholecystectomies (LC), the prevalence of CBD stones averages 6% (range: 3% to 10%). Out of 3,260 LCs with routine intraoperative cholangiography (IOC), the prevalence of CBD stones was 7.3% ( Frazee et al. , 1989; Phillips et al. , 1990; Sackier et al. , 1991; Bagnato et al. , 1991; Flowers et al. , 1992; Van Campenhout et al. , 1993; Corbitt and Yusem, 1994; Lezoche et al. , 1994; Carroll et al. , 1996 ) compared to 4.2% out of 2,478 LCs with selective IOC ( Bailey et al. , 1991; Lillemoe et al. , 1992; Grace et al. , 1993; Salky and Bauer, 1994; Barkun et al. , 1994; Robinson et al. , 1995 ).
The incidence of choledocholithiasis increases over the age of 60 ( Huguier et al., 1991 ).




1. Introduction

2. Preoperative detection

3. Intraoperative detection

4. Treatment

5. References


2. Preoperative detection of common bile duct stones

2.1. Do prognostic scores correctly identify patients with CBD stones?

To achieve a maximal benefit to risk ratio, radiological investigations of the CBD should be restricted to patients with high suspicion of CBD stones, as determined by preoperative predictive scoring.

In a study of 880 patients, Prat et al. (1999) showed that:
  • < 70 years old, predictors were: GGT >7 x normal, pathologic gallbladder, dilated bile duct;
  • > 70 years old, predictors were: GGT >7 x normal, fever >38°C, dilated bile duct.

A meta-analysis of 22 studies by Abboud et al. (1996) showed that:
  • factors increasing the risk of CBD stones 10-fold or more were:
cholangitis, preoperative jaundice, ultrasound evidence of common bile duct stones.
  • factors with an increased risk from 4-fold to 7-fold were:
dilated common bile duct on ultrasound, hyperbilirubinemia, jaundice.
  • factors with an increased risk of less than 3-fold were:
elevated levels of alkaline phosphatase, pancreatitis, cholecystitis, hyperamylasemia.

Huguier et al. (1991) showed that the risk of CBD stones is less than 2% if R <3.5
R = 0.04 X (age of patient) + 3.1 if CBD diameter >8 mm (ultrasonography)
+ 1.2 in presence of gallbladdder stones <10 mm
+ 1 in presence of biliary pain
+ 0.7 in presence of cholecystitis

These scores enable preoperative detection of most patients with a risk of CBD stones. Huguier’s score identifies patients with a risk of CBDS lower than 2%. In these patients, intraoperative cholangiography (IOC) is not required. However, there is a 2% risk of missing CBD stones, which actually represents about 15% of all choledocholithiasis.

2.2. What is the efficiency of radiological investigations?


2.2.1. Transcutaneous ultrasonography (US) and computed tomography (CT)
Preoperative US is a non-invasive and inexpensive method. Moreover, with real-time imaging, detection rates improve, ranging from 55% ( Cronan, 1986 ) to 82% ( Lindsell, 1990 ). The best results have been obtained in patients with dilated bile ducts ( Lindsell, 1990 ).
Studies of computed tomography report a CBDS detection rate of 82% to 90% ( Pedrosa et al., 1981; Baron et al., 1983; Jeffrey et al., 1983 ).

2.2.2. Three dimensional spiral CT cholangiography
3-D spiral CT cholangiography provides a good opacification of the biliary tree in most patients with a serum bilirubin level less than 3 mg/dl and without severe liver insufficiency ( Van Beers et al., 1994 ). For detection of CBDS, the sensitivity is 86%, the specificity 100%, the PPV 100%, the NPV 91% and overall accuracy 94% ( Stockberger et al., 1994 ).

2.2.3. Magnetic resonance cholangiopancreaticography (MRCP)
The sensitivity of magnetic resonance in detecting CBDS varies from 0.57 to 1 ( Dwerryhouse et al., 1998; Musella et al., 1998; Zidi et al., 1999; Varghese et al., 2000 ).
A specificity of 95.6%, a PPV of 92.6% and an NPV of 100% have been reported ( Demartines et al., 2000 ).
Detected calculi range from 2 to 20 mm ( Fulcher et al., 1998 ). However, calculi smaller than 3 mm might be missed in as many as 29% of patients ( Sugiyama and Atomi, 1998 ). Sensitivity decreases from 100 to 64% when stones are less than 3 mm in diameter ( Mendler et al., 1998 ).
MRCP is significantly more accurate when the CBD is dilated (89% for dilated CBDs vs 40% for non-dilated CBDs) ( Guibaud et al., 1995 ).
Figure
Figure 2.2.3

MRCP has the advantage of being safe, of requiring neither irradiation nor contrast medium injections and of showing a complete cholangiogram including anatomical variations ( Reinbold et al., 1996 ).
In addition, the failure rate of MRCP (due to contraindications and claustrophobia) is less than that of ERCP. Moreover, MRCP is possible in patients with duodenal stenosis or hepatico-jejunostomy.
MRCP also allows visualization of the pancreatic duct.

2.2.4. Endoscopic ultrasonography (EUS)
Endoscopic ultrasonography (EUS) is an invasive and sensitive endoscopic technique for the detection of choledocholithiasis.
In a prospective evaluation of 62 consecutive patients, Amouyal et al. (1994) found that EUS was significantly more sensitive (97%) than US (25%) and CT (75%). Specificity and PPV were not significantly different. However, the NPV of EUS (97%) was significantly better than that of US (56%) and CT (78%).

In contrast with other procedures, results did not depend on the size of the stones or the diameter of the bile duct. Rare false negatives with EUS are caused by stones located at the hepatic hilum (5-7 cm from the transducer). Denis et al. (1993) confirmed these results in 60 patients with choledocholithiasis, with a sensitivity of 92%, a specificity of 100%, a PPV of 100%, a NPV of 94% and an accuracy of 97%.

2.2.5. Endoscopic retrograde cholangiopancreatography
Cannulation of the CBD is successfully achieved in approximately 92% to 98% of patients.
Previous Billroth II gastrectomy and presence of ampullary duodenal diverticulum are technical limitations.
A study of 1,950 examinations described a major complication rate of 0.8% and a mortality rate of 0.1% ( Reiertsen et al., 1987 ). Severe pancreatitis and cholangitis occurs in 1% to 3% of patients ( Cotton et al., 1991 ).

In a prospective multicenter evaluation ( Lenriot et al., 1993 ) from a surgical recruitment of patients, the mortality and morbidity rate of ERCP (without ES) was estimated to be 0.96% and 3.6%, respectively. In this study, the sensitivity was 70%, the specificity 87%, the PPV 91% and the NPV 77%. A clear advantage of ERCP over MRCP is the ability to visualize the ampulla on endoscopy and to perform biopsies when and where indicated ( Reinhold and Bret, 1996 ). ERCP remains an invasive diagnostic procedure and should be reserved for patients in whom endoscopic treatment is preferred.




1. Introduction

2. Preoperative detection

3. Intraoperative detection

4. Treatment

5. References


3. Intraoperative detection of common bile duct stones

3.1. Intraoperative cholangiography

The main advantages of IOC during cholecystectomy are:
(a) detection of CBDS;
(b) reduction of the incidence of residual CBDS;
(c) delineation of the biliary anatomical variations at risk for bile duct injury.
IOC is a highly sensitive tool for detecting choledocholithiasis, with an overall accuracy of 95% ( Kitahama et al., 1986 ). Advocates of routine IOC argue that unsuspected CBDS will be identified in 1 to 14 % (average: 5%) of patients without indications for ductal exploration when routine IOC is used ( Farha and Pearson, 1976; Pagana and Stahlgren, 1980; Stark and Loughry, 1980; Kitahama et al., 1986 ).

In addition, biliary tract injury (BTI) might be prevented by defining biliary anatomy early in the procedure ( Fletcher, 1993 ). Opponents of routine IOC respond that the incidence of retained stones is not greater when IOC is performed selectively on the basis of clinical and laboratory criteria (less than 1%) ( Gerber, 1986; Grogono and Woods, 1986 ). Moreover, false-positive results of IOC range from 0.6% to 6% (average: 3.1%).
Four prospective randomized studies assessed IOC ( Soper and Dunnegan, 1992; Hauer-Jensen et al., 1993; Sharma et al., 1993; Nies et al., 1997 ). None of these studies showed a significant advantage of systematically performing IOC for patients in whom CBD stones are not suspected. Thus routine IOC cannot be recommended. However, by not performing IOC, CBD stones are overlooked in 2-3% of patients undergoing cholecystectomy, or in 15-20% of those with CBD stones.
Figure
Figure 3.1

3.2. How feasible is IOC during laparoscopic cholecystectomy?

With increased experience ( Voyles et al., 1994; Lezoche et al., 1994 ), successful laparoscopic IOC (LIOC) can be achieved in 90-99% of cases, a rate similar to that of IOC during OC.
The failure rate of laparoscopic IOC is related to:
  • the narrowness of the cystic duct;
  • cystic duct rupture;
  • obstructive cystic valves;
  • impacted cystic stones;
  • or dye extravasation from cystic duct perforation.

In two prospective series of 441 consecutive patients ( Bouillot et al., 1995; Millat et al., 1997 ), IOC was successful in 406 cases (92%) and the average time required was 13 min (range 5-25). Unsuspected stones were detected in up to 31% of cases with routine LIOC ( Bouillot et al., 1995; Millat et al., 1997 ). Residual stones were encountered in 0.8-1.4% with selective LIOC ( Bailey et al., 1991; Lillemoe et al., 1992, Grace et al., 1993; Barkun et al., 1993; Salky and Bauer, 1994; Robinson et al., 1995 ). False-positive results of routine LIOC occurred in 1% [0% -3%] of patients ( Flowers et al., 1992; Bouillot et al., 1995; Carroll et al., 1996; Millat et al., 1997 ), leading to unnecessary laparoscopic CBDE, conversion to open CBDE or postoperative ES.
Figure
Figure 3.2

3.3. Intraoperative ultrasonography

Many studies focused on the role of intraoperative ultrasonography (IOUS) in laparoscopic cholecystectomy ( Bilbao et al., 1976; Milutinovic et al., 1980; Classen and Phillip, 1984; Reiertsen et al., 1987; Vaira et al., 1989; Cotton et al., 1991; Metcalf et al., 1992; Barkun et al., 1993; Rothlin et al., 1996; Birth et al., 1998; Thompson et al., 1998; Siperstein et al., 1999; Machi et al., 1999 ). IOUS is technically demanding but is as accurate as IOC (88% to 100%) for screening CBDS.
The advantages of IOUS over IOC are:
  • speed;
  • safety;
  • unlimited use;
  • and low cost.
The greater sensitivity of IOUS examination concerned mainly small stones or debris in the CBD.
Figure
Figure 3.3.a

The disadvantages of IOUS include:
  • surgeons’ unfamiliarity with this modality;
  • the need for a special IOUS probe;
  • dependence on the operator’s experience and ability;
  • impossibility to provide extended views of the intrahepatic and extrahepatic biliary tree, impossibility to show passage of contrast into the duodenum and to identify bile duct injuries.
Finally, IOUS cannot replace IOC, but can be used in a complementary manner.
Figure
Figure 3.3.b

3.4. Intraoperative choledochoscopy

Intraoperative choledochoscopy should ensure a complete viewing of the intrahepatic and extrahepatic biliary tree.
The value of choledochoscopy has been confirmed in numerous studies ( Escat et al., 1984; Nagorney and Lohmuller, 1990; Menzies and Motson, 1992 ). Unsuspected stones after cholangiographic examination and/or ductal exploration are detected in 6-18% of cases by routine choledochoscopy. In addition, choledochoscopy during open CBD exploration (OCBDE) reduces the incidence of residual CBDS. In the DenBesten international survey of 1,072 consecutive biliary operations for stone disease, the incidence of retained CBDS was 4.5% and occurred almost exclusively in institutions in which IOC and choledochoscopy were omitted or infrequently used ( DenBesten and Berci, 1986 ).
Figure
Figure 3.4.a

Flexible choledochoscopes increase the efficiency of choledoscopy in detecting CBD stones. In a collective review of the literature, including more than 2,000 patients, Motson et al. (1990) reported an average retained stone rate of 3.6% (median: 3.3%) with a rigid choledochoscope and 2% (median: 1.85%) with a flexible choledochoscope.
Figure
Figure 3.4.b




1. Introduction

2. Preoperative detection

3. Intraoperative detection

4. Treatment

5. References


4. Treatment of common bile duct stones

In case of preoperative diagnosis of CBDS, options for management include:
(a) preoperative endoscopic retrograde cholangiopancreaticography (ERCP) and endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy (LC)
or
(b) conventional open common bile duct exploration (OCBDE)
or
(c) laparoscopic common bile duct exploration (LCBDE).

In 1991 Brodish and Fink reported the results of a survey among the members of the Society of American Gastrointestinal Endoscopic Surgeons (SAGES) regarding their choice of management for patients with preoperative suspicion of CBDS ( Brodish and Fink, 1993 ). When liver function test results were increased by more than one half the normal range, 73% of the responders recommended preoperative ERCP, while only 25% favored LCBDE if CBDS was suspected preoperatively. However, the optimal timing of the ERCP / ES remains open for discussion, with its use before or after LC. And today, most laparoscopic surgeons prefer the “single-stage” laparoscopic approach to choledocholithiasis ( Memon et al., 2000 ).

4.1. Preoperative or postoperative ERCP when suspicion of CBDS?

By waiting 24 to 48 hours after diagnosis, it has been shown that a good number of CBD stones pass spontaneously ( Hawasli et al., 2000 ). In a retrospective meta-analysis of the literature, Erickson and Carlson (1995) showed that performing ERCP after laparoscopic cholecystectomy significantly decreases costs and morbidity.

In a randomized study of patients presenting with mild acute pancreatitis from biliary origin and any of the following criteria on hospital day 4: CBD >8 mm, bilirubinemia >1.7 mg/L, amylasemia >150 UI/L, Chang et al. (2000) demonstrated laparoscopic cholecystectomy and selective postoperative ERCP/SE is associated with a shorter hospital stay, less cost, no increase in combined treatment failure rate, and significant reduction in ERCP use compared with routine preoperative ERCP.


(ERCP +/- ES) + (LC + IOC)
(LC + IOC) +/- (ERCP +/- ES)
n
30
 29
Apache II
3.1 +/- 2.1
 2.5 +/- 0.5
ERCP
30
 7 + 2
CBD stones/ES
12 (40%) / 11
 8 (28%) /7
ES morbidity
1 pancreatitis
 1 cholangitis
Overall stay (days)*
11.7 +/- 6.1
 9 +/- 3.2
Costs (US $)*
10,210 +/- 3839
 8,586 +/- 3520
* p < 0.05
ERCP: endoscopic retrograde cholangiopancreaticography
LC: laparoscopic cholecystectomy
IOC: intraoperative cholangiography
ES: endoscopic sphincterotomy
CBD: common bile duct

4.2. Endoscopic retrograde cholangiopancreaticography (ERCP) with endoscopic sphincterotomy or surgery for CBD stones? Randomized studies

None of the randomized trials published to date ( Neoptolemos et al., 1987; Stain et al., 1991; Stiegman et al., 1992; Hammarstrom et al., 1995; Targarona et al., 1996; Cushieri et al., 1996 ) concluded superiority of endoscopic treatment alone or associated with surgery as compared to first-line surgical treatment. Immediate postoperative mortality was 2.6% in the endoscopic group as opposed to 1% in the surgical group.
In Targarona’s study which included “high risk patients” ( Targarona et al., 1996 ), short-term mortality was 4% in the surgery group and 6% in the group undergoing ES without removal of the gallbladder. In global analysis, the rate of major and minor complications were respectively 8% and 10% after endoscopy followed by surgery, and 8% and 15% after surgery alone.
Figure
Figure 4.2.a

Multivariate analysis revealed that preoperative ES was an independent predictive variable of immediate postoperative complications ( Neoptolemos et al., 1989 ), and that ES not followed by surgery was significantly associated with the risk of recurring biliary symptoms during an average 17-month follow-up period. The rate of retained stones was 3.4% after endoscopy and surgery, and 4.9% after surgery alone. After a first ES, 95 patients out of 372 (25%) still had stones in the CBD. This rate decreased to 16% after spontaneous clearing of the stones or a second endoscopic extraction. An analysis of therapeutic intentions reveals that treatment failed for 97 out of 389 patients treated by ES (25%).
Figure
Figure 4.2.b

Randomized studies comparing laparoscopic common bile duct exploration to endoscopic sphincterotomy combined with LC showed that LCBDE and ERCP were equally effective in clearing the common bile duct of stones ( Cuschieri et al., 1996; Rhodes et al., 1998 ). But there was a significantly shorter hospital stay in patients treated by LCBDE.

Study of European Association for Endoscopic Surgery (EAES) ( Cuschieri et al., 1996)

LCBDE
(ERC +/- ES) + LC
p
n patients
n patients with
CBD (%)
133
109 (82)
 136
99 (73)
Failed ERCP +/- ES
23 (17)
Stone clearance
82/98 (84)
 ns
Successful
LCBDE (%)
92/109 (84)
 12/17 (71)
Conversions (%)
14 (13)
 5 (5)
 ns
Postoperative ES
3
Complications
21/133
 17/136
 ns
Deaths
0
 2
Hospital stay
(range)
6.4 (4.2-12)
 9 (5.5-14)
 < 0.05
ES: endoscopic sphincterotomy
LC: laparoscopic cholecystectomy
ERC: endoscopic retrograde cholangiopancreaticography

A second study reported by Rhodes et al. (1998) confirmed these results. 80 patients with CBD stones, which were diagnosed intraoperatively were included in a randomized trial comparing laparoscopy to ERCP +/- postoperative endoscopic sphincterotomy.

Laparoscopy
ERCP +/- ES
n
40
 40
Clearance (1st procedure)
30
 30
Additional ERCP
9
 7
Open CBDE
1
Stent, residual stone
2
Morbidity
7
 6
Duration (min)
90 (25-310)
 105 (60-255)
Hospital stay (median, days)
1 (1-26)
 3.5 (1-11)*
ERCP: endoscopic retrograde cholangiopancreatography
CBDE: common bile duct exploration
ES: endoscopic sphincterotomy
*p = 0.0001

4.3. Common bile duct stone complicated by cholangitis

Lau et al. (1996) randomly compared 41 ES and 41 surgical procedures in the framework of severe acute cholangitis. ES, as compared to surgery, significantly reduced the percentage of patients with:
  • complications (34% as opposed to 66%; p<0.05);
  • retained stones (7% as opposed to 30%, p<0.03);
  • mortality (10% as opposed to 32%; p<0.03).
Temporary naso-biliary drainage or internal prosthesis were also recommended ( Lau et al., 1996 ).
Figure
Figure 4.3

4.4. Conclusions

The results of these studies, in addition to the growing experience in laparoscopy, lead us to recommend that the first step in the treatment of CBD stones should be their surgical removal by laparoscopy, except for patients with acute cholangitis who should undergo ES.
In case of failure to remove stones, postoperative ERCP should be performed.



1. Introduction

2. Preoperative detection

3. Intraoperative detection

4. Treatment

5. References


5. References

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