Managing Common Bile Duct Stones
Common duct stones (choledocholithiasis) pose a high risk for complications and nearly always warrant treatment. There are various options available. It is not clear yet which one is optimal:
- In the past, when common bile duct stones were suspected, the approach was open surgery (open cholecystectomy) and surgical exploration of the common bile duct. This required a wide abdominal incision.
- Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) is now the most frequently used procedures for detecting and managing common duct stones. The procedure involves the use of an endoscope (a flexible telescope containing a miniature camera and other instruments), which is passed down the throat to the bile duct entrance.
- Laparoscopic cholecystectomy also is increasingly being used for detection and removal of common duct stones. This is an approach through the abdomen but uses small incisions. In such cases, it is used in combination with ultrasound or a cholangiogram (an imaging technique in which a dye is injected into the bile duct and x-rays are used to view any stones.)
Experts are currently debating the choice between laparoscopy (which is an abdominal approach) and ERCP (in which the approach uses a tube down the throat). Many surgeons believe that laparoscopy is becoming safe and effective and should be the first choice. Still, laparoscopy for common duct stones should be performed only by surgeons experienced in this new and demanding technique.
Circumstances for Selecting Specific Common Bile Duct Stone Procedures
Endoscopic Retrograde Cholangiopancreatography (ERCP)
Laparoscopic Common Bile Duct Exploration
Open Common Bile Duct Exploration (Choledocholithotomy)
- Before gallbladder surgeries when there is strong suspicion that common bile duct stones are present.
- After gallbladder surgeries in which the surgeon detects stones in the common bile duct (only if there are experts in ERCP and equipment is available).
- For patients with gallstone cholangitis (serious infection in the common bile duct). In such cases urgent ERCP plus antibiotics is required.
- When acute pancreatitis is caused by gallstones. In such cases urgent ERCP plus antibiotics is required. (The use of ERCP compared to conservative treatment has been controversial. One study reported that only patients who had infection and persistent obstruction in the ducts benefited from urgent ERCP intervention. In a 2000 analysis of four studies, however, ERCP significantly improved survival rates and reduced complications.)
- As an alternative to ERCP before gallbladder surgeries when there is high suspicion of common bile duct stones. (Should be performed only in centers with expertise in this procedure, where it may actually be preferable to ERCP.)
- During gallbladder surgeries when common duct stones are detected or highly suspected. (Only for centers with expertise in this procedure.)
- During or after some gallbladder operations when stones are detected. If procedure is laparoscopy, surgeon may convert to open procedure. Less often used now.
- When ERCP or laparoscopic procedures are not available.
Endoscopic Retrograde Cholangiopancreatography (ERCP) with Endoscopic Sphincterotomy (ES)
The ERCP and ES Procedure. A typical ERCP and endoscopy sphincterotomy (ES) procedure includes the following steps:
- The patient is given a sedative and asked to lie on his or her left side.
- An endoscope (a tube containing fiberoptics connected to a camera) is passed through the mouth and stomach and into the duodenum (top part of the small intestine) until it reaches the point where the common bile duct enters. This does not interfere with breathing, but the patient may have a bloating sensation.
- A thin catheter (tubing) is then passed through the endoscope.
- Contrast material (a dye) is injected through the catheter into the opening of the duct. The dye allows visualization using an x-ray of the biliary tree (the system of ducts through which bile flows, including the common bile duct) and any stones contained in the area.
- Instruments may also be passed through the endoscope to remove any stones that are detected.
- The next phase of the procedure is known as endoscopic sphincterotomy (ES). (It is also sometimes referred to as papillotomy, although this is a slightly different variation.) It serves to widen the junction between the common bile duct and intestine (called the ampulla of Vater) so that the stones can be extracted more easily. With ES a tiny incision is usually made in the orifice of the common bile duct and through the muscles that enclose the lower common bile duct (called the sphincter of Oddi).
- One recent alternative to ES is the use of a small inflatable balloon (called endoscopic balloon dilation) that opens up the ampulla of Vater to allow stones to pass and so avoid cutting the muscles. According to 2003 studies, it is equal in effectiveness to ES but offers no advantage at this time.
- Once the junction has been opened, the stones may pass out on their own or they may be extracted with the use of tiny baskets or balloons.
Complications. Complications of ERCP and ES occur in 5% to 8% of cases, and some can be serious, with mortality rates of 0.2% to 0.5%. They include the following:
- Pancreatitis (inflammation of the pancreas) occurs in 3% to 9% of cases and can be very serious. Younger adults are at higher risk than the elderly. The risk is also higher with more complex procedures. The drugs somatostatin or gabexate are sometimes used to reduce the risk. Gabexate appears to be more effective, although studies are mixed on whether its benefits are significant, particularly with short-term administration. (Evidence suggests that somatostatin does not reduce this risk.)
- Post-operative infection. Antibiotics may be given before the procedure to prevent infection, although one study reported that they had little benefit.
- Bleeding occurs in 2% of cases. There is an increased risk in patients taking anti-clotting drugs and those who have cholangitis. This complication is treated by flushing the area with epinephrine.
- Perforations (rare).
- Long-term complications include stone recurrence and abscesses.
ERCP and ES are difficult procedures and patients must be certain their physician and the medical center are experienced with them. The surgeon should have performed at least 180 ERCPs. Under such circumstances, ERCP can usually be performed successfully even in critically ill patients on mechanical ventilators.
ERCP and Gallbladder Removal (Cholecystectomy). ERCP is often performed after gallstones in the common duct are discovered during cholecystectomy (removal of the gallbladder).
In some cases, stones in the gallbladder are detected during ERCP. In such cases laparoscopic cholecystectomy is usually warranted. There is some debate about whether the gallbladder should be removed in such cases at the same time as ERCP or if patients should wait. A 2002 study suggested that immediate gallbladder removal is preferred, since the risk for recurring symptoms is very high.
Laparoscopic Common Bile Duct Exploration and Cholangiography
Surgeons are now increasingly using laparoscopy plus an imaging technique called cholangiography instead of ERCP when common duct stones are suspected.The laparoscopic procedure for common duct stones should be performed only in centers where there is expertise. It generally proceeds as follows:
- The initial approach is the same as with laparoscopic cholecystectomy. Small incisions, one or two 10 to 12 mm (around half an inch) and three 5 mm (.20 inches), are made in the abdomen.
- A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiogram. (In this procedure, a dye is administered to reveal the stone's location on x-rays.)
- The procedure is typically used in combination with cholangiography, an imaging technique in which a dye is injected into the bile duct and x-rays are used to view any stones. Cholangiography reduces the risk for injury in the common duct.
- If stones are identified, the surgeon inserts a tube with an inflatable balloon that is used to widen the duct.
- Stones are usually retrieved or withdrawn from the duct either with the use of a balloon or with a tiny basket.
- If laparoscopy is unsuccessful, then ERCP or open surgery is performed.
Experts are debating whether the use of this procedure is better than ERCP. Many surgeons believe that laparoscopy is becoming safe and effective and should be the first choice. Still, laparoscopy for common duct stones should be performed only by surgeons experienced in this new and demanding technique.
Open Common Bile Duct Exploration (Choledocholithotomy)
Choledocholithotomy, or common bile duct exploration, is used to remove large stones or in cases when the duct anatomy is complex. In this procedure, the physician carries out open abdominal surgery and extracts gallstones through an incision in the common bile duct. Routinely, a so-called T-tube is temporarily left in the common bile duct after surgery and the physician x-rays the bile duct through the tube seven to ten days postoperatively to determine if any stones remain in the duct.
Lithotripsy for Common Bile Duct Stones
Shock wave lithotripsy is an option in certain cases for bile duct stones that cannot be extracted.
- Mechanical Endoscopic Lithotripsy. Endoscopy with mechanical lithotripsy employs a tiny steel crushing basket, which is inserted through the endoscope and into the common bile duct. The basket opens to trap and then crush the stone. It is capable of crushing and removing very large stones. The overall success rate is 80% to 90%, although 20% to 30% of patients require more than one treatment.
- Extracorporeal Shock Wave Lithotripsy. Extracorporeal shock wave lithotripsy is an option in certain cases of bile duct stones as it is for stones in the gallbladder.