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retained cbd stone

Background: Common bile duct (CBD) stones may be over looked at the time of laparoscopic cholecystectomy (LC), particularly when intra-operative cholangiography (IOC) is not performed. Currently, there is no data available about the time course and pattern of presentation for stones retained in the CBD at the time of LC. The aim of this study was to establish the time course and pattern of presentation of unsuspected retained CBD stones post LC.

Methods: Patients presenting with symptomatic CBD stones from 1994 until 2010, having previously undergone LC were studied in this retrospective, case note review. CBD stones were confirmed at ERCP. Data collected included LC date, mode of presentation, imaging results including CBD diameter, stone appearance, length of stay and post ERCP complications. Patients having an ERCP for stones found on IOC at LC were excluded.

Results: Sixty-one patients met the inclusion criteria. The most common mode of presentation was abdominal pain (n = 38, 62%) with (17) or without (21) deranged liver function tests. Nineteen (31%) patients presented with clinical complications of the CBD stones: cholangitis (10), acute biliary pancreatitis (6) or obstructive jaundice (3). The CBD was usually mild-to-moderately dilated (8-15 mm) on ultrasound. The median time span from LC to presentation with CBD stones was 4 years (range: 6 days-18 years). Five (8.2%) patients had a complication from their ERCP; mild pancreatitis (3), bleed (1) and cholangitis (1). Nineteen (31.1%) patients required more than one ERCP to complete stone/stent removal.

Retained cbd stone

The diagnostic workup of patients with symptomatic cholelithiasis usually begins with biochemical tests of liver function and systemic inflammation and diagnostic imaging (abdominal ultrasonography or CT). Any imaging data transferred to the internal medicine department at the time of the patient’s referral should be reevaluated by a radiologist. Although ultrasonography provides reliable imaging of the bile duct in most cases, its accuracy is sometimes limited by colonic gas, obesity, anatomical variations, and the sonographer’s experience. The specialist should then determine whether any blood biochemical markers (e.g., alkaline phosphatase, total bilirubin, aspartate transaminase, and alanine transaminase) are elevated. If ultrasonography is unable to evaluate the entire bile duct in patients with abnormal liver function markers, noncontrast CT should be performed to rule-out potential CBD stone. Noncontrast CT should be favored because fasting and the use of contrast media are generally unnecessary and it is relatively inexpensive, although it is unable to detect radiolucent stones. Contrast-enhanced CT scan can also be used as a primary imaging modality, and this is usually performed in an emergency room or at another hospital. If suspected GB stone is invisible on CT images, ultrasonography could be performed as an ancillary imaging modality. The high likelihood of a CBD stone in patients with typical abdominal symptoms and liver function test abnormalities without visible CBD stone can prompt some specialists to perform magnetic resonance cholangiopancreatography (MRCP). In our institution, our policy is to remove all CBD stones by ERCP first, and then perform laparoscopic cholecystectomy. Intraoperative cholangiography is not routinely performed. Postoperatively, all patients are checked with biochemical tests (complete blood cell count and liver function tests) and non-contrast CT at one month after LC.

Biliary surgeons may experience frustration when patients who undergo cholecystectomy subsequently present with retained common bile duct (CBD) stones after discharge, despite the absence of CBD stones on preoperative or postoperative check-ups. Such patients are likely to be referred to internal medicine specialists for diagnosis and subsequent treatment. The original surgeon is likely to feel culpable for declaring complete recovery and may suffer a loss of rapport with the patient. Other issues include the medical expenditure associated with the diagnosis and treatment of retained CBD stones, the risk of complications associated with endoscopic retrograde cholangiopancreatography (ERCP), and increased patient distress [1,2].

Conclusion

Department of Surgery, Seoul Metropolitan Government-Seoul National University Boramae Medical Center, Seoul National University College of Medicine, Seoul, Korea.

To investigate the prevalence and clinical features of retained symptomatic common bile duct (CBD) stone detected after laparoscopic cholecystectomy (LC) in patients without preoperative evidence of CBD or intrahepatic duct stones.

Methods

Cost-effective diagnosis and subsequent management of retained CBD stones are controversial. The initial workup of patients with suspected cholelithiasis is usually involves transabdominal ultrasonography or CT at an outpatient clinic or emergency center, depending on the patient’s clinical setting, the institutional protocol, or the attending clinician’s preference. Because transabdominal ultrasonography is often limited in terms of the ability to detect distal CBD stones, it is possibly inadequate to identify patients who are highly likely to have CBD stones. In addition, it is undeniable that CT shows limited ability to detect calcium-free radiolucent stones. Although recent studies [20,21] suggested that helical CT cholangiography can be used to diagnose CBD stones with sensitivity and specificity similar to magnetic resonance cholangiography, its use as a primary radiologic imaging modality seems to be inappropriate from a cost-effectiveness perspective. In addition, Ammori et al. [22] proposed that a “wait and see” policy of observation alone for patients with small bile duct calculi detected at intraoperative cholangiography (IOC) during laparoscopic cholecystectomy appears to be safe, and is more cost-effective than routine postoperative ERCP. Furthermore, some studies have suggested that the most cost-effective treatment strategy for most patients with symptomatic cholelithiasis involves laparoscopic cholecystectomy with routine IOC, as IOC can help laparoscopists to visualize the biliary anatomy and detect unexpected CBD stones [23,24]. However, it remains debated whether IOC provides sufficient benefits in terms of its efficacy and safety to justify its routine application. Indeed, several studies [6,25] have shown that IOC in addition to routine laparoscopic cholecystectomy of symptomatic cholelithiasis did not improve the detection rate of unexpected CBD stones or bile duct injury, but did increase the operation time. IOC can also complicate the surgical procedure and increase the risk of adverse complications. Needless to say, MRCP and endoscopic ultrasonography show high diagnostic accuracy for CBD stones owing to their accurate visualization of the biliary system without invasive instrumentation. However, the appropriate timing of these procedures is being investigated with respect to their cost-effectiveness. Bahram and Gaballa [26] advocated routine preoperative MRCP to reduce the incidence of postoperative complications and to detect unexpected CBD stone. However, other studies [12,27] opposed routine MRCP owing to its poor cost-effectiveness. Nevertheless, if CBD stones are strongly suspected in patients with bile duct dilatation, the presence of liver function abnormalities should justify the use of MRCP or endoscopic ultrasonography.