PubMed · 3738781
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F L Kiechle, M S Weisenfeld, R E Karcher, E Epstein. 1986. Liver function tests and choledocholithiasis.. https://pubmed.ncbi.nlm.nih.gov/3738781/
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BACKGROUND: Occasionally patients present to the surgeon with known common duct stones. These will frequently have been detected by imaging modalities: ultrasound, computed tomography (CT) scans, transhepatic cholangiogram (THC) or IV cholangiography. Occasionally there are stones that had failed attempts at endoscopic retrieval (ERCP). METHODS: A retrospective analysis of a prospectively gathered database of 77 laparoscopic common bile duct explorations was done to assess the incidence, treatments and outcomes of patients who had known common duct stones (CDS) before surgery. RESULTS: Eighteen patients (23%) were identified as having a preoperative diagnosis of CDS. All underwent a laparoscopic common bile duct exploration. This exploration was successful in all cases. Outcomes were good with a 4% complication rate and one case of retained common duct stones (4%). CONCLUSIONS: Before laparoscopic cholecystectomy, known choledocholithiasis was considered a surgical disease except in cases of acute cholangitis or the very morbidly ill. The ability to perform cholecystectomy laparoscopically made many practitioners avoid open common duct exploration and, instead, rely on ERCP as primary treatment for known or suspected common duct stones. As techniques of laparoscopic common duct exploration improve, the ability to deal with common duct pathology surgically has increased, offering new options for treatment of this patient population. We present our experience with 18 patients who presented with known choledocholithiasis and were treated laparoscopically with good results.
A 51-year-old man had repeated admissions and discharges from the hospital for alcohol dependence and alcoholic hepatitis. Thereafter, with a diagnosis of chronic pancreatitis, he was examined on an outpatient basis. He presented with right hypochondriac pain as the chief complaint, and was admitted to the hospital because of a suspected acute exacerbation of chronic pancreatitis. Pyrexia and jaundice were present from about the 5th hospital day, and he was admitted to Kurume University Hospital with a diagnosis of obstructive icterus. Percutaneous transhepatic biliary tract drainage (PTBD) was immediately performed. A roentgenogram revealed moderate dilatation of the extrahepatic bile ducts and stricture of the intrapancreatic common bile duct. No calculi were observed in the gallbladder or bile ducts by ultrasonography of the abdominal region. The main pancreatic duct was dilated to 10 mm, and a strong echo, probably a calculus, was observed in the main pancreatic duct. Pancreatoduodenectomy was performed with a diagnosis of stricture of the common bile duct due to chronic pancreatitis with a pancreatic stone. Examination of the excised specimens revealed a rigid pancreatic head; and when the common bile duct was incised, no stricture was observed. A milk-white calculus about 10 mm in diameter was observed in the common channel of the lower portion of the common bile duct. The orifice of the pancreatic duct was also observed at the same site. The common channel was about 20 mm long, and malfusion of the pancreatobiliary ducts was observed. The obstructive icterus was due to an impaction of the pancreatic stone at the confluence of the pancreatobiliary ducts. The calculus was composed of calcium carbonate, and the histopathological findings in the pancreas showed chronic pancreatitis.
Although the common bile duct is now accessed using a coelioscopic approach by an increasing number of surgical equipes, the problems related to the diagnostic iter of lithiasis of the common bile duct and the need to obtain a correct preoperative diagnosis, in order to select the most appropriate form of therapy, are of growing topical importance. Following a revision of the literature, the authors focus their attention on those studies which seem to be most interesting and important in relation to the criteria for suspected lithiasis of the common bile duct, studied in single, multivariable and preoperative analyses, namely without taking account of perioperative analyses, namely without taking account of perioperative criteria. These studies reveal the most statistically significant criteria for predicting lithiasis of the common bile duct. Although the application of these studies is not practicable, they undoubtedly arouse considerable interest. The authors have selected the simple criteria whose rigorous application may result in the selection of patients with 0 criteria, with a 1% risk of non-suspected lithiasis of the common bile duct. Perioperative cholangiography (POC) and echoendoscopy are closely correlated to these criteria. The authors outline their diagnostic iter within the framework of a prospective study they carrying out.