Spontaneous passage of common bile duct stones in jaundiced patients

Rhyl, UK

Spontaneous passage of common bile duct stones in jaundiced patients

Valentina Lefemine and Richard John Morgan

Rhyl, UK

BACKGROUND: Common bile duct (CBD) stones are known to pass spontaneously in a significant number of patients. This study investigated the rate of spontaneous CBD stones passage in a series of patients presenting with jaundice due to gallstones. The patients were managed surgically, allowing CBD intervention to be avoided in the event of spontaneous passage of CBD stones.

METHOD: Retrospective analysis of patients presenting with jaundice due to CBD stones, and managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram with or without CBD exploration.

RESULTS: The jaundice settled pre-operatively in 76/108 patients, and in 60/108 the CBD stones had passed spontaneously by the time of surgery. These 60 patients avoided any intervention to their CBD.

CONCLUSIONS: CBD stones pass spontaneously in more than half of jaundiced patients. Surgical management (laparoscopic cholecystectomy and intra-operative cholangiogram, with willingness to perform CBD exploration if positive) allows the avoidance of CBD intervention in these patients.

(Hepatobiliary Pancreat Dis Int 2011; 10: 209-213)

cholecystectomy; cholangiogram; common bile duct stones

Introduction

Common bile duct (CBD) stones are known to occur in 10%-15% of patients with symptomatic gallbladder stones.[1-3]They can present in a number of ways or may be asymptomatic. Common presentations include biliary pain, jaundice, acute pancreatitis, acute ascending cholangitis, or a combination of these.

The management of symptomatic CBD stones has evolved over recent decades, and continues to evolve. Laparoscopic CBD exploration has emerged as an alternative to endoscopic retrograde cholangiopancreatography (ERCP) and a successor to open CBD exploration for the management of CBD stones.[4-8]Laparoscopic CBD exploration has been shown to be as efficient as pre-operative ERCP[9,10]with no significant difference in morbidity and mortality, but with the advantages of a single stage procedure.

Jaundice is an emotive symptom which, understandably, often leads to alarm in the patient, their family and carers. After initial investigation, patients with jaundice due to CBD stones are often subjected to urgent invasive procedures to relieve the biliary obstruction, such as ERCP[11]or surgical exploration of the CBD.[12]There is a risk of morbidity (and mortality) with these interventions.[13,14]However, it is a common clinical observation that jaundice (due to CBD stones) may resolve spontaneously. Evidence is accumulating to show that CBD stones often pass spontaneously.[15,16]This raises the possibility of avoiding any CBD intervention altogether, if the CBD stones can be proven to have passed spontaneously.

This study investigated the rate of spontaneous passage of CBD stones in a group of patients presenting with jaundice. These patients were managed surgically with laparoscopic cholecystectomy and intra-operative cholangiogram (and laparoscopic CBD exploration if positive for CBD stone). Those patients in whom the bile duct stones had passed spontaneously thus avoiding bile duct intervention.

Methods

A consecutive series of patients referred over a 5-year period with biochemically confirmed jaundice (we chose a bilirubin measurement of more than 51 mmol/L three times the upper limit of normal--as confirmation of jaundice) and sonographic evidence of gallstones were studied retrospectively by case-note review. Those patients who had undergone urgent ERCP for acute pancreatitis (our policy is that these patients undergo early ERCP in accordance with the British Society of Gastroenterology's guidelines[7]) or cholangitis were excluded from the study. Patients with indications for ERCP (i.e. acute pancreatitis or cholangitis), but who had recovered before an ERCP could be arranged, were included in the study, as were patients who had undergone an unsuccessful attempt at ERCP prior to referral to our department. Patients whose jaundice had started to settle prior to their referral were also included in the study. Those in whom the initial investigations had suggested a malignant cause of their biliary obstruction were excluded, as were those considered unfit for surgery.

The clinical presentations of the patients were recorded. Each patient in the study was investigated initially with abdominal ultrasonography. Further investigations, e.g. with magnetic resonance cholangiopancreatography (MRCP), CT scan or endoscopic ultrasound (EUS) were not routinely performed. The results of pre-operative ultrasound were compared with the findings on intraoperative cholangiogram.

All patients were offered laparoscopic cholecystectomy with on-table cholangiogram, and bile duct exploration in the event of positive cholangiogram. For those patients who were currently jaundiced at presentation, a watch and wait policy (with monitoring of liver function tests) was adopted for 2-3 days in order to determine if the jaundice was settling. Those patients whose jaundice settled were offered a delayed operation after a period of approximately 4 weeks. This period was chosen as an estimate to allow the greatest chance of bile duct stones passing spontaneously, with minimum risk of further bile duct stones appearing. Patients in whom the jaundice did not settle within two or three days underwent urgent surgery.

The rate of positive cholangiograms and bile duct explorations was recorded, and the bile duct diameter on the cholangiogram was measured in all cases. Bile duct explorations were performed either trans-cystically with a 3-mm flexible choledochoscope (Richard Wolf, Knittlingen, Germany) or trans-ductally with a 5-mm flexible cystoscope (Karl Storz, Tuttlingen, Germany). Bile duct stones were usually extracted using a Dormia basket (Cook, Letchworth, UK), or were flushed into the duodenum. T-tubes were used selectively, e.g. when there was a suspicion of incomplete CBD clearance.

Results

One hundred and eight patients (61 females and 47 males) were included in the study. Thirteen were referred after an unsuccessful or incomplete attempt to clear the CBD at ERCP. Twenty were referred after their jaundice had started to settle. The presenting symptoms (apart from jaundice) varied considerably within the study group (Table 1).

Of the 108 patients, 76 showed an initial improvement in their jaundice, and underwent delayed (2-12 weeks) laparoscopic cholecystectomy. This group included 56 patients who were jaundiced at time of referral and the rest 20 patients whose jaundice had started to settle at referral. The longer delays in the series represent these 20 patients. In the remaining 32 patients, the jaundice failed to settle within 2-3 days of the initial presentation, and urgent surgery was undertaken.

Cholecystectomy was performed laparoscopically in all 108 patients, but in 14 patients (13%) conversion to open surgery was necessary. Intra-operative cholangiography was successfully performed in 106 of the patients (success rate 98%); it was unsuccessful for technical reasons in 2 patients undergoing delayed surgery. These 2 patients had normal liver function tests post-operatively, and had no post-operative evidence of retained CBD stones; they therefore avoided CBD intervention. It is assumed that the CBD stones that caused their jaundice had passed spontaneously. The intra-operative cholangiogram was normal in 58 patients (54%). Forty-eight patients (44%) had abnormal findings and underwent laparoscopic CBD exploration.

Of the 32 patients who required emergency laparoscopic cholecystectomy, 25 (78%) had a positive cholangiogram. In the group of patients undergoing delayed operative intervention, only 23 out of 76 (30%) had a positive cholangiogram showing CBD stones, which implied that 70% of the patients had spontaneously passed a bile duct stone.

Every patient in whom the cholangiogram revealed the presence of filling defects proceeded to CBDexploration. Twenty patients (42%) had their CBD explored via the trans-cystic route, and 28 (58%) via the trans-ductal route. Exploration of the CBD (and common hepatic duct in trans-ductal explorations) in all of these patients revealed the presence of one or more gallstones, which were removed using a Dormia basket, or were flushed away into the duodenum. Three patients (in whom T-tubes were placed) required post-operative ERCP for residual CBD stones, giving an overall completion rate of 94% for CBD exploration. Two of these patients requiring post-operative ERCP had undergone urgent surgery for non-settling jaundice; one had undergone an unsuccessful attempt at ERCP prior to referral for surgery.

Table 1. Clinical presentation

Table 2. Pre-operative ultrasound findings and the corresponding outcomes of intra-operative cholangiography

The median CBD diameter in the patients who underwent CBD exploration was 8 mm (range 5-24 mm). In the patients with no stones seen at cholangiography the median CBD diameter was 7 mm (range 4-14 mm). The pre-operative ultrasound findings and the corresponding outcomes of intra-operative cholangiography are shown in Table 2.

Of the 20 patients who presented late, after their jaundice had started to resolve, four (20%) had a positive cholangiogram and underwent CBD exploration.

There were two post-operative deaths in the series (mortality rate ＜2%); neither was directly related to the biliary surgery. One patient died of fecal peritonitis due to perforated sigmoid diverticular disease, following a transductal CBD exploration. Another died of cardiac and renal failure following an otherwise uncomplicated laparoscopic cholecystectomy with negative cholangiogram.

Peri-operative complications occurred in further four patients (4%); one had a bile leak from the choledochotomy, which settled spontaneously, and another leaked from a cystic duct laceration, requiring ERCP and stenting. In two further patients the duodenum was inadvertently lacerated; one of these patients required conversion to open operation for repair of the laceration.

Discussion

This study was devised to investigate the rate of spontaneous passage of CBD stones in jaundiced patients, and to demonstrate that this phenomenon allows surgical management (laparoscopic cholecystectomy) without CBD intervention.

It proved impossible to identify a standard definition for the biochemical correlates of clinical jaundice. We therefore chose a bilirubin level of three times the upper limit of normal (17 mmol/L) in our laboratory. All patients had been documented by a medical practitioner to be clinically jaundiced.

We chose to include patients whose jaundice was already improving, or had resolved, at the time of referral. We considered them still to be at risk of having a bile duct stone (dis-impaction alone may have allowed the jaundice to resolve), and many such patients would otherwise be referred for ERCP. We chose not to use MRCP, CT or EUS to exclude CBD stones in our patients, as is commonly practiced,[17-19]because of concerns that CBD stones could recur between a negative scan and the definitive operation.

The results of this study show that more than half of patients who present with jaundice due to CBD stones pass their stones spontaneously. This allowed them to be managed surgically, in many cases, without the need for endoscopic or surgical intervention to the bile duct.

It is theoretically possible that retained CBD stones were missed, when a cholangiogram was interpreted as normal, but no cases of retained stones have come to light on follow up. Measurements of the CBD at cholangiography showed that the duct was generally less dilated when no stones were found, but even when the duct diameter was up to 14 mm, no retained stones have come to light.

A minority of patients in our study had persistent jaundice (and persistently elevated serum levels of bilirubin), which did not settle during a short period of observation. In these patients the incidence of CBD stones (identified on intra-operative cholangiography) was higher than that in patients in whom the jaundice did settle. In the latter cohort, the patients in this study underwent delayed operative intervention and the majority of them had spontaneously passed their CBD stones. These results suggest that delaying surgery in patients whose jaundice improves clinically and biochemically during the initial observation period reduces the number of patients requiring CBD exploration. It is interesting to note, however, that the spontaneous passage of bile duct stones could not be accurately predicted by the resolution of the jaundice. Nor could the spontaneous passage of CBD stones be predicted from the findings of the initial ultrasound scan. Further studies are required to determine moreaccurately which patients are likely to pass their CBD stones spontaneously. Another area for further research is the optimum timing of delayed surgery in patients whose jaundice settles.

Spontaneous passage of CBD stones is well recognized.[15,16,20]Tranter et al[15]conducted a study on a cohort of 1000 patients in an attempt to determine the rate of spontaneous intraductal stone passage and relate it to the various clinical presentations of bile duct stones. They concluded that most bile duct stones (3 in 4) pass spontaneously, especially in patients with pancreatitis, biliary colic and cholecystitis, but less commonly in painless jaundiced patients. Nevertheless, 55% of jaundiced patients included in their study passed CBD stones spontaneously. These findings are in keeping with those of our study.

Collins et al[16]reported that the incidence of choledocholithiasis is 3.4% in patients selected to undergo laparoscopic cholecystectomy. None of these patients were jaundiced or had biliary ductal dilatation. The authors advocate a policy of conservative management of asymptomatic and clinically silent CBD stones as more than one third of these patients will pass the calculi spontaneously. This approach has the obvious advantage of sparing surgical or endoscopic exploration of the CBD, with their attendant risks. Another study by Sakai et al[21]used MRCP to confirm the clinical suspicion that CBD stones had passed spontaneously. Our study group differed from those of Collins and Sakai et al, consisting only of patients presenting with jaundice; nevertheless the rate of spontaneous passage of bile duct stones was greater than 50%. It should be feasible to extend the policy of conservative management of bile duct stones, advocated by Collins, to jaundiced patients, in the expectation that the majority of bile duct stones would pass spontaneously.

In conclusion, over half of jaundiced patients may pass their bile duct stones spontaneously. A policy of laparoscopic cholecystectomy with on-table cholangiogram (and a willingness to perform laparoscopic bile duct exploration in those patients who did not pass their stones spontaneously) allows these patients to be successfully managed without endoscopic or surgical bile duct intervention. In the majority of patients, the jaundice settles spontaneously within a few days, allowing for delayed surgery with a greater chance (compared with urgent surgery) of spontaneous passage of the CBD stones.

Acknowledgement

We would like to thank Mr. Salman Anwer and Fayyaz Axbar for their help in data collection.

Funding: None.

Ethical approval: Not needed.

Contributors: LV wrote the first draft of this commentary. Both authors contributed to the intellectual context and approved the final version. MRJ is the guarantor.

Competing interest: No benefits in any form have been received or will be received from a commercial party related directly or indirectly to the subject of this article.

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Received November 13, 2010

Accepted after revision January 19, 2011

News

Liver transplantation in Indonesia

Living donor liver transplantations were performed at the Cipto Mangunkusumo Hospital and Puri Indah Hospital, Indonesia University with the support from a team headed by Prof. Shu-Sen Zheng, the First Affiliated Hospital, Zhejiang University School of Medicine on December 12-17, 2010. During the 1-week period, four patients with end-stage liver diseases received such operations including adult living donor liver transplantation for 3 patients and pediatric living donor liver transplantation for 1.

Prof. Zheng shaking hands with former president of Indonesia University School of Medicine after performing an operation.

A network of services between the two universities has been established since then, providing for example a real-time consultation on internet between the doctors from both sides after Chinese doctors came back on January 4, 2011.

Reported by Lei SY

Email: hbpdje@gmail.com

Prof. Zheng at the bedside of a recipient of living donor liver transplantation.

Author Affiliations: Department of General Surgery, Glan Clwyd Hospital, Rhyl, UK (Lefemine V and Morgan RJ)

Richard John Morgan, MD, Department of General Surgery, Glan Clwyd Hospital, Rhyl, LL18 5UJ, UK (Tel: 01745-534334; Fax: 01745-534688; Email: richard.morgan@wales.nhs.uk)

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