Stones in the bile duct: Clinical features and open surgical approaches and techniques

Overview

The first successful common bile duct exploration (CBDE) by Thornton in 1889 and the introduction of catheter-based biliary decompression by Courvoisier and Kehr marked the initial efforts in treating choledocholithiasis. Open cholecystectomy and bile duct exploration were performed commonly as the standard treatment for patients with choledocholithiasis for many years with good success and low rates of morbidity and mortality ( Table 37A.1 ). During this era of open operative interventions, the percentage of retained stones was only 1% to 3%, and long-term follow-up revealed that revisional surgery was necessary in about 10% of the patients.

TABLE 37A.1

Mortality Rates of Biliary Reoperation for Retained or Recurrent Bile Duct Stones

REFERENCE	NUMBER OF OPERATIONS	NUMBER OF DEATHS (%)
Saharia et al. (1977)	30	0
Jones (1978)	22	0
McSherry & Glenn (1980)	341	7 (2%)
Allen et al. (1981)	47	1 (2%)
De Almeida et al. (1982)	22	1 (5%)
DenBesten & Berci (1986)	86	2 (2.3%)
Girard (2000)	88	0
TOTAL	920	15 (1.6%)

In the last several decades, however, there has been a shift away from open cholecystectomy and CBDE with improvements in noninvasive imaging and increasing sophistication of percutaneous and endoscopic interventions (see Chapters 19 , 29 , 30 , and 36 C). Beyond the widespread availability of endoscopic retrograde cholangiopancreatography (ERCP), the increased use of laparoscopy and minimally invasive techniques has made open CBDE an infrequently used tool. The significant trend toward laparoscopic surgery including cholecystectomy, intraoperative cholangiogram (IOC), and CBDE over the last several decades has impacted the experience of surgical trainees. This has resulted in limited experience in open biliary surgery, specifically open cholecystectomy and open CBDE. Chief residents complete training with an average of a single CBDE, open or laparoscopic.

Although the majority of cholecystectomies are now performed laparoscopically (see Chapter 35 ), laparoscopic CBDE (LCBDE; see Chapter 36 B) has not been similarly embraced. This is in part because of the wide availability of ERCP but also in part because the technical demands of LCBDE do not lend themselves to routine use by most general surgeons. Surveys of general surgeons practicing in a rural area of the United States demonstrated that the preferred approach to choledocholithiasis was ERCP (75%), followed by laparoscopic (21%) or open (4%) exploration. Analysis of practice patterns in large hospital systems more than a decade later found a similar underutilization of LCBDE with less than 30% of patients undergoing a single-stage laparoscopic cholecystectomy with LCBDE. There is also broad variability in terms of evaluation and treatment of choledocholithiasis across geographic regions. A multicenter trial found that when choledocholithiasis was suspected, laparoscopic cholecystectomy with IOC was the most common initial procedure in seven institutions followed by ERCP in four and magnetic resonance cholangiopancreatography (MRCP) in one.

Despite these considerations, there remain indications for open CBDE. This chapter presents a review of the clinical features of choledocholithiasis with an emphasis on the technical aspects of open CBDE.

Origin of choledocholithiasis

CBD stones are broadly classified by their location of origin (see Chapter 32 ). Secondary stones, those that originate in the gallbladder and migrate into the bile duct, are the most common. Chemically, these stones tend to be cholesterol or black-pigment stones. Primary CBD stones, in contrast, originate within the CBD and are predominantly brown-pigment (calcium bilirubin) stones. Primary stones occur in patients with congenital absence of the gallbladder and in those whose CBD had been cleared at the time of prior cholecystectomy. CBD stones that occur in the immediate postcholecystectomy period should be assumed to be secondary stones that are the result of an incompletely cleared CBD. Secondary stones are the most commonly observed CBD stones, particularly in Europe and North America. Primary stones are encountered more commonly in Asia and are associated with a high incidence of intrahepatic bile duct stones seen in Southeast Asian countries such as Taiwan, Hong Kong, and Singapore (see Chapter 39 ). The relative prevalence of intrahepatic bile duct stones in all gallstone cases in Taiwan is extremely high (>50%) and coexisting intrahepatic and extrahepatic bile duct stones are found in approximately 70% of these patients.

Typical presentations for inflammatory, infective, and congenital choledocholithiasis include biliary colic, jaundice, cholangitis (see Chapter 43 ), and pancreatitis (see Chapter 55 ). Of these, pain from biliary colic tends to be the most common symptomatic manifestation of CBD stones. In many cases, the intermittent obstruction and passage of CBD stones will result in fluctuating elevation of bilirubin and hepatocellular enzymes. If untreated for a long period of time, these recurrent episodes may lead to secondary biliary cirrhosis. In contrast to the intermittent obstruction that results in biliary colic, persistent CBD obstruction can result in cholangitis, which may display the Charcot’s classic triad (fever/rigors, jaundice, and right upper quadrant pain) or the Reynold’s pentad (Charcot’s triad plus hypotension and altered mental status) (see Chapter 43 ). Pancreatitis is the second most frequent symptomatic presentation of CBD stones (see Chapter 55 ), and depending on the timing of cholangiography, CBD stones can be identified in up to 50% of these patients. Patients who have symptomatic bile duct stones are at risk of experiencing further symptoms or complications if left untreated. More than one-half of patients who had retained bile duct stones experienced recurrent symptoms during a follow-up period of 6 months to 13 years, and 25% developed serious complications. The potential for serious sequelae related to CBD stones makes the identification and definitive treatment of patients with CBD stones of great importance.

The potential long-term sequelae of untreated clinically significant stones have led some to advocate for routine intraoperative cholangiography at the time of cholecystectomy so that clearance of the duct at the time of surgery can be ensured. The clinical significance and natural history of asymptomatic CBD stones, however, is unpredictable, as many small stones will pass spontaneously without incident. During the era of open cholecystectomy, the practice of routine cholangiography was common, and studies from this period demonstrated an incidence of choledocholithiasis approaching 10% to 15% in patients without any clinically evident common duct involvement. Proponents of a more selective approach to cholangiography, however, note that the percentage of clinically significant stones is far lower than the 10% to 15% of patients who will have cholangiographic findings of CBD stones when routine cholangiography is used.

The use of selective intraoperative cholangiography in laparoscopic cholecystectomy series demonstrates similar findings. Collins and colleagues identified filling defects consistent with stones in 4.6% of patients on IOC. In these patients, access was maintained for the performance of postoperative cholangiograms. At 48 hours, 26% of patients had a normal cholangiogram, and an additional 26% had evidence for passage of the stones by 6 weeks. Only 22 patients (2.2%) had persistent CBD stones at 6 weeks after laparoscopic cholecystectomy and underwent ERCP for retrieval.

Preoperative diagnosis

In the absence of clinical signs such as cholangitis or pancreatitis, preoperative identification of choledocholithiasis typically relies on serum liver function tests (LFTs) and imaging studies. The utility of LFTs in predicting the presence of CBD stones has been demonstrated by a number of groups. ^, Serum bilirubin and alkaline phosphatase are typically the most commonly used laboratory values; however, a raised γ-glutamyltransferase (GGT) level has been suggested to be the most sensitive and specific laboratory indicator of CBD stones. A GGT value greater than 90 U/L has been proposed to indicate a high risk of choledocholithiasis, with sensitivity and specificity of 86% and 75%, respectively.

Transabdominal ultrasound (TUS) alone has a low sensitivity (25%–60%) for detection of CBD stones and is highly operator dependent. ^, When used in conjunction, clinical examination, laboratory studies, and ultrasonography (typically the first-line imaging modality) (see Chapter 15 ) are sensitive in 96% to 98% and specific in 40% to 75% for identification of patients with choledocholithiasis. Liu and colleagues stratified precholecystectomy patients into four groups of descending risk of choledocholithiasis based on guidelines incorporating clinical evaluation, serum chemistry analysis, and TUS. The occurrence of choledocholithiasis in these groups (group 1, extremely high risk; group 2, high risk; group 3, moderate risk; group 4, low risk) was 92.6%, 32.4%, 3.8%, and 0.9%, respectively. Triaging patients in this manner resulted in preoperative identification of choledocholithiasis by ERCP in 92.3% of the patients who were subsequently referred for endoscopic clearance. Similarly, the American Society of Gastrointestinal Endoscopy (ASGE) identified several predictors of choledocholithiasis in their guidelines for the use of endoscopy in the evaluation of CBD stones. CBD stones seen on TUS or cross-sectional imaging, clinical evidence of ascending cholangitis, and bilirubin greater than 4 mg/dL were identified as high-risk criteria for choledocholithiasis and patients should move directly to ERCP. They suggest that any other risk factors, such as those mentioned previously, should prompt additional investigation with MRCP, endoscopic ultrasonography (EUS), or IOC at the time of cholecystectomy. ERCP requires cannulation of the papilla and is associated with a significant risk of adverse events in up to 15% of patients and severe adverse events including death or prolonged hospital stay in approximately 2%. For this reason, ERCP should be reserved for individuals in the high-risk category or with CBD stones confirmed by MRCP or EUS. When taken in sum, these data suggest that the ERCP is best reserved as a therapeutic measure for patients with a high probability of CBD stones, rather than as an initial diagnostic test.

Like TUS, standard computed tomography (CT) scanning has a low sensitivity for the detection of bile duct stones and is most useful in documenting biliary dilation or excluding mass lesions as a cause of biliary obstruction (see Chapter 18 ). Newer techniques of CT cholangiography use contrast agents excreted in the biliary tree, which when combined with high-resolution helical scans and three-dimensional reconstructions can give accurate and detailed information about the biliary tree. ^, The sensitivity of this technique can be as high as 97%, and the specificity is 75% to 96%. Although these data suggest accuracy comparable to MRCP (see Chapter 19 ), helical CT cholangiography is limited by several issues: (1) possible allergic reactions to the contrast agents (as high as 15% in one series using intravenous iotroxate), (2) suboptimal ductal contrast opacification in the presence of significant jaundice, ^, and (3) limited visualization of intrahepatic duct branches. ^,

MRCP has become the gold standard for noninvasive biliary imaging since its introduction in 1991 and has been recommended by some as the preoperative noninvasive modality of choice for the detection of CBD stones (see Chapter 17 ). MRCP provides precise anatomic detail of the biliary tract and has a sensitivity of 81% to 100% and a specificity of 92% to 100% in detecting choledocholithiasis. ^, The accuracy of MRCP in diagnosing CBD stones is comparable with that of ERCP (see Chapters 19 and 20 ) and IOC (see Chapter 23 ). ^, As a diagnostic test, MRCP has largely replaced ERCP, once considered the gold standard of preoperative bile duct imaging, because the nonselective use of ERCP in all patients with suspected choledocholithiasis detects CBD stones in less than 50%. ^, Although both MRCP and ERCP are effective at detecting choledocholithiasis, a randomized trial looking at an MRCP first versus ERCP first approach to patients with suspected CBD stone disease found equivalent patient outcomes. Importantly, those in the MRCP arm were 50% less likely to have a subsequent ERCP.

Indiscriminate use of ERCP exposes over half of patients to unnecessary procedure-related morbidity and mortality ; thus ERCP is better used as therapeutic intervention rather than a diagnostic one. Although MRCP is currently the most accurate noninvasive imaging modality for choledocholithiasis, it may miss stones smaller than 5 mm in diameter and can underestimate the number of stones detected. Furthermore, it is expensive when compared with TUS or CT, not readily available at smaller facilities, and may not be technically feasible in obese patients or those with significant claustrophobia.

EUS has also emerged as an alternative to ERCP and MRCP for preoperative assessment of bile duct stones and was initially described in 1990 ^, (see Chapter 16 ). EUS and MRCP are both highly accurate in detecting choledocholithiasis, with EUS having a slight edge because of its increased sensitivity at detecting small stones (97% vs. 90%). EUS may be particularly useful in patients in which MRCP may be limited such as patients with obesity, claustrophobia, metal clips, cardiac pacemaker, or inability for breath holding. EUS also provides the advantage of immediate transition to therapeutic ERCP if diagnostic findings warrant. A systematic Cochrane review of the literature, including 18 studies involving 2532 participants, found both EUS and MRCP to be highly accurate at diagnosing CBD stones and found no difference in sensitivity or specificity between the two modalities. Randomized controlled trials (RCTs) have also demonstrated that EUS-guided ERCP can avoid unnecessary ERCP in up to two-thirds of patients when compared with using ERCP alone for diagnosis of choledocholithiasis. Furthermore, selective use of ERCP based on EUS findings resulted in reduced risk of overall complications and post-ERCP pancreatitis (PEP).

Timing and sequence of interventions

Suspected choledocholithiasis before cholecystectomy

In patients with suspected choledocholithiasis, selecting and sequencing the laparoscopic, open, and endoscopic therapeutic modalities can be challenging. Before the popularization of therapeutic laparoscopy, precholecystectomy endoscopic clearance of the CBD was uncommon. Several studies did not reveal any morbidity or mortality advantage with preoperative endoscopic sphincterotomy (ES) and one actually showed an increased rate of morbidity in patients who underwent preoperative ERCP, followed by open cholecystectomy, compared with the group that was treated with single-stage open cholecystectomy and CBDE. A systematic review of the literature, including eight trials with 737 participants, comparing open CBDE versus ERCP for clearance of CBD stones found no significant difference in morbidity or mortality. However, open CBDE was more effective at clearing CBD stones than ERCP.

The expansion of therapeutic laparoscopy saw a rise in the popularity of preoperative ERCP CBD clearance for patients with suspected choledocholithiasis, in part because laparoscopic CBDE is more technically challenging than laparoscopic cholecystectomy alone (see Chapters 36 B and 36 C). For surgeons who are comfortable with LCBDE, the data support single-stage laparoscopic management (laparoscopic cholecystectomy and IOC with CBDE in those with CBD stones) over preoperative ERCP, followed by laparoscopic cholecystectomy. Several prospective RCTs compared these two treatment strategies (Cuschieri et al., 1999; Rogers et al., 2010; Sgourakis et al., 2005) and found that the two groups had equivalent success rates of duct clearance and patient morbidity, but a significantly shorter hospital stay was reported with the single-stage laparoscopic treatment. ^, ^, Single-stage laparoscopic cholecystectomy with LC + CBDE results in fewer procedures, the shortest length of stay and most cost-effective treatment for patients with CBD stones. Despite these findings it continues to be underutilized in measures of current practice patterns with less than one-third of patients received single-stage LC + LCCBDE versus laparoscopic cholecystectomy with preoperative or postoperative ERCP.

When LCBDE is not part of the surgeon’s armamentarium, the decision to perform a precholecystectomy ERCP should be weighed carefully because it is not without complications. Although most post-ERCP complications are mild to moderate in severity, the risk of severe complications, such as pancreatitis, bleeding, infection, and perforation, need to be weighed against the likelihood that ERCP will find clinically relevant CBD stones. ERCP has an overall complication rate of 10% and a mortality rate less than 0.5%. In a systematic review of 108 RCTs with 13,296 participants the incidence of PEP was 9.7% and up to 14.7% in the high-risk population. Most cases are mild to moderate and the mortality rate associated with PEP was 0.7%. Despite advances in equipment and techniques the rate of PEP has not decreased in the modern experience with a rate of 10% in studies since 2000. Additionally, the increased financial cost of preoperative ERCP should be considered when evaluating its role in the treatment of suspected stones.

Accurately predicting which patients will have clinically relevant choledocholithiasis can be challenging. Several studies have shown that a “negative” ERCP is performed in 40% to 70% of patients because most of these biochemical and radiographic abnormalities were the result of transient biliary obstruction secondary to stones that passed preprocedurally into the duodenum. ^, ^, ^, ^, As mentioned earlier in this chapter, the 2019 ASGE guidelines suggest immediate ERCP for patients in the high-risk category: (1) CBD stone on ultrasound or cross-sectional imaging, (2) total bilirubin >4 mg/dL and dilated CBD, and (3) ascending cholangitis. EUS or MRCP are recommended for intermediate-risk patients, whereas low-risk patients may proceed to cholecystectomy. Treatment strategies for patients stratified to the low- and high-likelihood groups are generally agreed on. Patients who are in the low risk for choledocholithiasis group should go directly to laparoscopic cholecystectomy (with or without IOC) because CBD clearance is unlikely to be necessary.

For patients in the high-risk group, particularly those needing biliary decompression for treatment of acute cholangitis and in patients with severe gallstone pancreatitis and evidence of persistent choledocholithiasis, precholecystectomy ERCP is warranted. Patients with multiple medical comorbidities, limited life expectancy, or other issues that would make them poor surgical candidates, ERCP with ES and biliary decompression can sometimes be used as the definitive management without cholecystectomy ^, (see Chapter 29 ). This strategy is not ideal for patients who are acceptable surgical candidates, however, because there is a risk of recurrent biliary symptoms if cholecystectomy is not performed. In a prospective randomized trial published in 1995 by Hammarström and colleagues, an expectant policy after ES was compared with open cholecystectomy combined with CBDE. It was reported that 20% of the patients after ES alone needed cholecystectomy during follow-up. A prospective randomized trial of high-risk patients performed by Targarona and colleagues (1996) comparing ES and subsequent open cholecystectomy to ES alone resulted in similar findings. They noted patients who underwent elective open cholecystectomy had significantly fewer recurrent biliary symptoms (6% vs. 21%) and needed fewer readmissions (4% vs. 23%) than patients who did not undergo surgery after ES.

In contrast to the general consensus of how to treat high- and low-likelihood patients, the question of how to treat intermediate-risk patients has been the subject of some debate. A recent RCT examined an up-front cholecystectomy and IOC strategy against preoperative ERCP and subsequent cholecystectomy for intermediate-risk patients. Fifty patients were randomized to each group, and differences in length of stay, number of subsequent CBD interventions, morbidity, mortality, and quality of life were analyzed. No significant difference was found in morbidity or quality of life; however, patients who underwent cholecystectomy as the initial procedure had a significantly shorter length of stay (median, 5 days vs. 8 days; P < .001) and fewer common duct investigations. A systematic review of seven trials including 746 participants compared single-stage LC + LCBDE versus two-stage preoperative ERCP + LC or LC + postoperative ERCP. The authors found no difference in morbidity or mortality but a lower rate of retained stones in the single-stage group. Together a single-stage LC + CBDE provides the best clearance of the bile duct, the shortest length of stay, and is more cost-effective with equivalent morbidity and mortality.

Common bile duct exploration at time of open cholecystectomy

Therapeutic laparoscopy has become routine in much of the world, and as laparoscopic experience has grown, surgeons have become increasingly more comfortable using LCBDE when choledocholithiasis is noted intraoperatively. In areas of the developing world, however, where access to endoscopic, radiologic, and laparoscopic expertise is limited, open cholecystectomy and bile duct exploration remains a mainstay of treatment. Even in settings where laparoscopy and endoscopy are readily available, however, there will still be some patients in whom an open approach to CBDE may be required (see Chapters 36 B and 36 C). Principal among these include patients with (1) large or impacted CBD stones and who have failed previous endoscopic interventions; (2) a need for biliary enteric drainage; (3) anatomic considerations that preclude endoscopic treatment, such as prior gastric resection, gastric bypass or duodenal diverticula; and (4) complex situations requiring an open approach for cholecystectomy, including those with Mirizzi syndrome, biliary-enteric fistula, severe cholecystitis, or a high index of suspicion for cancer.

Postcholecystectomy choledocholithiasis (see Chapter 38 )

Incidence

The majority of initial operations for gallstone disease, with or without demonstrated choledocholithiasis, are curative, but some patients will develop sequelae of choledocholithiasis postcholecystectomy. Approximately 1% to 2% of all patients who undergo cholecystectomy have stones left in the CBD that require further intervention. Retained calculi occur rarely after open cholecystectomy without CBDE (Bergdahl & Holmlund, 1976), whereas the incidence in those who undergo open cholecystectomy with concomitant CBDE is slightly higher but still reported to be less than 5%. Retained CBD stones occur with higher frequency after positive CBDE than after a negative one. The rate of recurrence increases to approximately 20% after a second operation on the biliary tract for choledocholithiasis, ^, and this rate increases after subsequent reoperation.

Treatment

Endoscopic and percutaneous methods remain the preferred modalities when managing recurrent or retained CBD stones (see Chapters 30 and 36 C). The open surgical approach is reserved for patients who have failed nonoperative treatments. Decision making is further influenced by clinical presentation, condition of the patient, institutional expertise, and presence or absence of a T-tube.

Retained stones in the presence of a T-tube.

Along with the rise in popularity of laparoscopic biliary surgery decreasing use of T-tube biliary drainage has also occurred. When LCBDE is performed, primary closure has been shown to be safe, and routine use of postexploration T-tubes is no longer common (see Chapters 31 and 42 ). If a T-tube is present, it provides nonsurgical options for accessing the biliary tree postoperatively. In the presence of a T-tube, retained CBD stones in the immediate postoperative period can be managed with observation, mechanical extraction, or ES.

In the initial weeks after CBDE, 10% to 25% of retained stones found on postoperative cholangiography will pass spontaneously into the duodenum, and as such interventions are not undertaken, assuming there is no evidence of obstruction or cholangitis. If calculi persist after 4 to 6 weeks, treatment options include radiologic approach through the T-tube tract (see Chapter 30 ) or ERCP (see Chapter 29 ). Because of its high success rate and low morbidity and mortality, nonoperative mechanical extraction through the T-tube tract is an attractive treatment choice. A success rate of 95% has been reported with a morbidity rate of only 4%, Burhenne reported no deaths in a series of 661consecutive patients. When complications do occur, they can be treated medically in most instances, and only 0.2% of cases have required surgery.

ES also has been shown to be effective in the management of retained stones in the early postoperative period after exploration of the CBD with a T-tube still in place. ^, Although ES has the considerable advantage that it can be carried out as soon as retained stones are discovered, treatment may be unnecessary in some patients because stones may pass spontaneously. Some authors have suggested that mechanical stone extraction through the T-tube tract is superior to ES because of its high success rate and lower morbidity profile, although modern endoscopic equipment may mitigate some of the post-ERCP hemorrhagic complications seen in earlier series. ^, Regardless, the safety and efficacy of percutaneous intervention through the T-tube makes it an ideal choice for initial postoperative interventions, and ES is best used in the early postoperative period before a T-tube tract is well formed, if the patient is clinically unstable, the T-tube is inappropriate in size and position, or mechanical extraction through the T-tube has failed. If these techniques fail, operative management can be undertaken with the expectation of a high success rate and acceptable morbidity and mortality. ^,

Retained or recurrent stones in the absence of a T-tube.

ES is the procedure of choice and should be attempted first in patients without a T-tube in place ^, (see Chapters 29 and 36 C). Most reports of ES indicate a success rate in achieving overall clearance of stones from the CBD of more than 85%. ^, ^, Although early complication rates for ES range from 5% to 15%, emergency surgery is uncommonly required and most complications can be managed conservatively. Hemorrhage, pancreatitis, cholangitis, and perforation are the most frequent complications, and mortality usually is reported at 0.5% to 2%. ^, Long-term complication rates, mainly from stenosis or new stones or both, are low (<10%), and most complications can be managed endoscopically. ^, ^, ^,

Although initial ES has a success rate of 80% to 90% stents may be placed when the duct cannot be completely cleared of stones for biliary drainage and subsequent attempts at clearance. The success rate of subsequent attempts varies widely in the literature from 44% to 96% and success depends on size, shape, and number of residual stones. The 2019 ASGE guidelines recommend ES with large balloon dilation in patients with difficult or large CBD stones. A meta-analysis of nine RCTs found ES + large balloon dilation more effective at stone clearance than ES alone (odds ratio [OR] 2.8). Lithotripsy, either mechanical or cholangioscopy assisted, is an effective technique to address difficult or refractory stone disease. Success rates also vary widely in the literature and frequently require multiple attempts with a complication rate up to 25%. The most common complication being cholangitis. Additionally, percutaneous transhepatic rendezvous techniques can sometimes aid in duct clearance, particularly if there is difficulty cannulating the ampulla. Often, however, failures of endoscopic management will be the result of large impacted stones or anatomic issues that are not ameliorated by a percutaneous approach. Definitive stenting with metal stents in uncleared ducts carries a high rate of morbidity and mortality and should be approached with caution. In such settings, operative management is the most reasonable alternative. Reoperation for retained stones can be performed safely, with operative mortality less than 2%. Miller and colleagues reported 237 patients with CBD stones treated by CBDE or ES. Success was higher and mortality was lower for the operatively managed group. The complication rate was similar, but the complications tended to be more serious and more apt to require surgery in the ES group. A systematic review performed by Dasari and colleagues found that duct clearance in patients undergoing open bile duct exploration was superior to ES, but it should be noted that most series that compare open cholecystectomy/CBDE to ES are from the era of open surgery, which also corresponds to the early days of ERCP and ES. Therefore caution should be used in extrapolating these data to the modern endoscopic experience. Nevertheless, these findings reinforce that surgery can be a valuable, effective, and safe tool in the treatment of recurrent/retained CBD stones, even if confined to the subset of patients who fail ES.

In patients with anatomy that is unfavorable for conventional ERCP and ES such as those with history of gastric resection or gastric bypass, laparoscopic-assisted ERCP provides an alternative approach for CBD clearance. Laparoscopic-assisted ERCP utilizes a laparoscopic approach to the remnant stomach, which is accessed via trocar for introduction of the duodenoscope for conventional ERCP. A multicenter study of 579 patients looking at laparoscopic-assisted ERCP in patients with previous Roux-en-Y gastric bypass found a procedure success rate of 98% with an adverse event rate of 18%. Adverse events were related to laparoscopy in 10% and ERCP in 7% and both in 1%. The gastrostomy can be closed surgically at the end of the procedure or a G-tube left in place for subsequent access if indicated. Together this is a viable alternative for certain patients, although it carries a higher complication profile than conventional ERCP + ES alone.

When reoperation is required for retained CBD stones, the optimal procedure is complete removal of all stones via choledocholithotomy, choledochoscopy, placement of a T-tube (in many cases), and completion cholangiography. This procedure is adequate for most patients, and the overall failure rate has been reported as low as 3%. Others, however, have reported significantly higher failure rates, ^, which has prompted some authors to recommend biliary-enteric drainage in all patients with previous choledocholithotomy. ^, Tompkins and Pitt (1982) and Cameron (1989) emphasized, however, that concomitant biliary drainage should not be regarded as mandatory procedure in all patients with retained or recurrent stones. ^, In general, biliary-enteric drainage at reoperation is appropriate in the following scenarios: (1) stricture or stenosis of the distal bile duct or sphincter of Oddi, (2) marked dilation of the duct of 2 cm or more, (3) multiple or primary bile duct stones, (4) inability to remove all stones from the duct, and (5) a third operation.

Transduodenal sphincteroplasty, choledochoduodenostomy, and choledochojejunostomy are effective methods of biliary enteric drainage (see Chapter 31 ). With the wide availability of ERCP, operative sphincteroplasty is rarely required because ES is sufficient in most cases. In the presence of a long distal CBD stricture, ES is not an appropriate choice because it does not address the primary obstructive issue. For ducts smaller than 1 to 1.5 cm in diameter, sphincteroplasty is the preferred operative approach as this avoids possible anastomotic stricture formation, but it does carry a greater risk of postoperative pancreatitis. Occasionally, recurrent or primary stones will be seen in patients with dilated ducts and a widely patent sphincter after sphincteroplasty or sphincterotomy. In such cases, choledochoduodenostomy or Roux-en-Y choledochojejunostomy is necessary. Side-to-side or end-to-side choledochoduodenostomy and end-to-side Roux-en-Y choledochojejunostomy are excellent drainage options for CBDs larger than 1.5 cm and offer better decompression of an extremely large duct. CDD can be performed end to side or side to side depending on the situation. Although side to side has been reported to have a higher rate of sump syndrome more recent reviews have not found this to be the case. In the context of previous biliary pancreatitis, patients who present for reoperation with multiple stones and an incompletely cleared proximal biliary system may be better served with an end-to-side choledochoduodenostomy as opposed to a side-to-side technique because it minimizes the chance of stones dropping distally and causing recurrent pancreatitis. Sump syndrome, the development of cholangitis, hepatic abscess, or pancreatitis caused by stones, sludge, or debris or food lodged in the CBD obstructing normal biliary drainage, is an uncommonly observed complication of choledochoduodenostomy and should be managed initially by endoscopic modalities. If ERCP fails to improve symptoms, the choledochoduodenostomy can be converted to a Roux-en-Y choledochojejunostomy. Laparoscopic or open approaches to choledochoduodenostomy are options with a low complication rate that allow easier subsequent endoscopic access to the biliary tree and more physiologic biliary drainage and do not require an entero-enteric anastomosis.

Clinical experience with reoperation

Girard reviewed all patients who underwent reoperation for retained or recurrent choledocholithiasis at the Maisonneuve-Rosemont Hospital between 1969 and 1990. Eighty-five patients with preoperatively confirmed choledocholithiasis underwent a total of 88 operations. Eighty-five of these operations were second procedures, and three patients required a third operation. Three types of bile duct reoperation were performed: choledocholithotomy with T-tube drainage (64 patients), choledocholithotomy with side-to-side choledochoduodenostomy (15 patients), and choledocholithotomy with transduodenal sphincteroplasty (6 patients). Choledocholithotomy with T-tube drainage in one patient and choledocholithotomy with side-to-side choledochoduodenostomy in two patients were performed at a third operation. The average hospital stay was 9.3 days. There were no deaths in the series despite the fact that 43 of 85 patients were older than 60 years and 44 patients had associated risk factors. Six minor complications were observed, none of which necessitated urgent surgery. Two patients (3%) of the 64 who had choledocholithotomy with T-tube drainage developed recurrent bile duct stones 4 and 5 years after a second operation, and side-to-side choledochoduodenostomy was performed.

To summarize, ES has become the first-line therapy for retained or recurrent bile duct stones, but surgery can be performed safely with low mortality and morbidity when required. Surgery remains a critical component of the armamentarium that can be used to treat recurrent bile duct stones. As with most things in modern medicine, a multidisciplinary approach to recurrent CBD stones is important to properly select and sequence the numerous options now available. Gastroenterologists, radiologists, and surgeons should work together closely to assess the most appropriate intervention for an individual patient. In making the choice between open surgery, laparoscopic surgery, percutaneous therapies, and ES, the surgeon must consider not only the published data but institutional expertise and experience. In a patient with a retained stone and a T-tube in place, percutaneous extraction through the T-tube tract or ES should be attempted first. In the absence of a T-tube, ES should be attempted first. If unsuccessful or contraindicated, operative management is a reasonable alternative. Surgical intervention has a high success rate and acceptable rates of mortality and morbidity. Before operation, the surgeon must make an accurate diagnosis of retained stones by using a combination of MRCP, ERCP, and EUS. These findings should be confirmed via intraoperative cholangiography and complete clearance of the biliary tree documented with completion cholangiography and choledochoscopy. Not all patients require biliary-enteric drainage, but certain patients, particularly those with multiple or incompletely cleared calculi, large ducts (>2 cm), and distal CBD strictures will benefit from drainage procedure.

Surgical techniques for exploration of the common bile duct

The principal techniques for open exploration of the CBD will be detailed in this section. Broadly, the goals of CBDE include complete clearance of calculi from the biliary system and establishment of free flow of bile into the gut. The preferred approach to CBDE is typically through a supraduodenal choledochotomy, with the transduodenal/transampullary route reserved for patients with impacted stones that cannot be removed readily from above. Stones impacted at the ampulla can be broken down and removed through a supraduodenal approach; however, a transduodenal sphincteroplasty is generally less traumatic.

Clearance of the biliary tree should be confirmed by performing postexploratory choledochoscopy and cholangiography. The value of choledochoscopy has been confirmed by many authors. ^, ^, Postexploratory cholangiography should also be performed before closure of the abdomen, not only because it can locate missed stones, but also because it may reveal unsuspected disruption of the biliary ductal system. If the cholangiography technique is meticulous, issues with false positives from air bubbles and poor opacification of the entire system can be largely eliminated to provide consistent and reliable cholangiograms.

The selective use of biliary-enteric drainage procedures is another method to decrease the incidence of subsequently symptomatic retained stones. Although we do not recommend routine biliary-enteric decompression at initial operation, it should be considered carefully in patients with multiple stones, large stones, dilated duct, distal bile duct stricture, and in selected elderly patients. If these conditions pertain to an elderly or poor-risk patient, choledochoduodenostomy may obviate reexploration. Other indications include (1) the presence of irretrievable intrahepatic stones, (2) proven ampullary stenosis, or (3) an impacted ampullary stone.

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