and Western countries. The majority (75%) of these stones are cholesterol stones with only a minority

being black-pigmented stones.66,67 It is estimated that approximately 10% to 15% of patients with

symptomatic gallstones will have CBD stones and the vast majority of patients with secondary CBD

stones will have gallstones.68,69

Clinical Presentation

7 CBD stones, similar to gallbladder stones, can have an asymptomatic course and pass spontaneously

into the duodenum without clinical consequence.69 The exact incidence and frequency in which this

occurs is unknown. In nonjaundiced patients with nondilated bile ducts on US, the incidence of CBD

stones at the time of cholecystectomy is approximately 5% with one-third of these patients passing the

stone(s) spontaneously (Fig. 61-12).

When symptomatic, the presentation of CBD stones can vary between mild biliary colic to fulminant

sepsis from acute cholangitis, biliary pancreatitis, or hepatic abscesses. Biliary colic is the most common

presentation and it is characterized by intermittent RUQ abdominal pain due to the increased pressure

that develops within the obstructed bile duct. These episodes can also be associated with jaundice and in

the absence of a superimposed bile infection this process can occur sporadically over time as the stone

intermittently obstructs the flow of bile, resulting in development of acute ascending cholangitis. Biliary

pancreatitis is the second most common presentation of CBD stone disease.

Predictors of Common Bile Duct Stones

There is no single biochemical or radiologic test that accurately predicts the presence of CBD stones.

Numerous studies have assessed the predictive value of serum liver biochemical tests (total bilirubin,

alkaline phosphatase, ϒ-glutamyl transpeptidase, alanine aminotransferase, and aspartate

aminotransferase) and the utility of transabdominal US in predicting the diagnosis of CBD stones.

Although liver biochemical tests have a strong negative predictive value of 97%, they only have a

positive predictive value of 15% to 50% when they are abnormal in patients with suspected CBD

stones.70,71 Transabdominal US is a valuable test in diagnosing gallbladder stones however, its utility in

detecting CBD stones is poor with a sensitivity of 22% to 55%.72 Therefore, a thorough history and

physical examination, in conjunction with the appropriate biochemical and imaging studies, are required

when clinical suspicion for CBD stones exists.

Table 61-4 A Proposed Strategy to Assign Risk of Choledocholithiasis in Patients

with Symptomatic Cholelithiasis Based on Clinical Predictors

Numerous prognostic nomograms, formulas, and algorithms have been developed to assist the

clinician in establishing the diagnosis of CBD stones.72 The American Society for Gastrointestinal

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Endoscopy proposed a risk-stratification scheme based on common predictive factors previously

identified (Table 61-4).72 Using this scheme, patients can be categorized into low (<10%), intermediate

(10% to 50%), or high (>50%) probability of choledocholithiasis. This scheme has subsequently been

validated in a large multi-institutional series of patients with suspected choledocholithiasis.73

Diagnostic Studies

Biochemical Liver Profile

Serum chemistry analysis of liver enzymes (AST and ALT) as well as total bilirubin and alkaline

phosphatase levels are routinely performed in patients being evaluated for calculous biliary pathology.

Elevated total bilirubin (>4 mg/dL) and alkaline phosphatase levels have typically been correlated with

the presence of CBD stones. In addition, elevated gamma-glutamyltransferase levels, although not

routinely obtained, has been correlated with the presence of CBD stones with a sensitivity of 85%.

Ultrasonography

Transabdominal US (Fig. 61-13A) plays a critical role in the diagnosis of gallbladder stones and has the

advantages of being noninvasive, widely available, and inexpensive. Unfortunately, studies have shown

that US is limited in its ability to reliably detect CBD stones (sensitivity of 15% to 30%); primarily due

to its inability to adequately assess the distal CBD because of overlying bowel in this region. The value

of US in the assessment of CBD stones is in its ability to detect a dilated CBD. A normal CBD diameter is

3 to 6 mm although a mild increase in CBD diameter with increasing age can be seen.74 A CBD diameter

≥8 mm is considered abnormal and suggestive of CBD stones in a jaundiced patient with gallstones.

The sensitivity in detecting a dilated CBD on US is 77% to 87% with a negative predictive value of 95%

when a normal CBD is seen.71 It is important to note that CBD stones can still be present in the absence

of a dilated CBD.

Endoscopic ultrasound (EUS) is a semi-invasive procedure that can assess for distal CBD stones with a

sensitivity and specificity of 88% to 94% and 94% to 95%, respectively.75,76 EUS is superior to other

invasive diagnostic studies in its ability to detect small (<5 mm) CBD stones and is associated with an

extremely low complication rate (0.1% to 0.3%).77 Certain treatment algorithms are recommending an

EUS-first approach prior to ERCP in patients at intermediate risk of CBD stones, when the diagnosis of

choledocholithiasis is unclear, or in patients with severe gallstone pancreatitis. If no stones are seen on

EUS, an ERCP can be avoided. Use of this approach will depend on the local expertise and availability of

this technology and the increased clinical and financial costs must be taken into consideration.

Laparoscopic intraoperative US using a high-frequency (7.5- to 10- MHz) probe allows for successful

evaluation of the CBD in 88% to 100% of cases with a sensitivity of detecting CBD stones of 71% to

100%.78 In addition, laparoscopic US, similar to EUS, allows for the adequate evaluation of the distal

bile duct for stones. It is important to note that all types of US modalities are limited by the inability to

provide a therapeutic intervention.

Computed Tomography

Overall helical CT (Fig. 61-13B) has shown a slighter better sensitivity (65% to 88%) and specificity

(73% to 97%) rate in detecting CBD stones when compared to transabdominal US. This comes at an

increased cost to the healthcare system and potentially unnecessary radiation exposure. The utility in CT

is its ability to assess for other conditions that may have similar presenting symptoms as CBD stones. CT

cholangiography has not been widely adopted across centers and therefore is still in evolution.

Magnetic Resonance Imaging

Magnetic resonance cholangiopancreatography (MRCP) has proven to be a useful adjunct in the

diagnosis of CBD stones (Fig. 61-13C). MRCP has the advantage of being noninvasive and providing

detailed biliary anatomy. This comes at an increased cost as well as an inability to provide any

therapeutic intervention. The accuracy of detecting CBD stones with MRCP is between 93% and 100%

and it has a sensitivity of 85% to 92% and specificity of 97%.79,80 Recent data suggest that MRCP may

not be that sensitive in detecting small CBD stones, as evidenced by a sensitivity of 33% to 70% in

patients with CBD stones <6 mm.81 Selective use of MRCP in patients at low and intermediate risk of

CBD stones can identify patients who may benefit from an endoscopic or intraoperative bile duct

exploration.

Cholangiography

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8 The gold standard in the diagnosis of CBD stones has been direct cholangiography. This traditionally

has been accomplished by invasive methods such as ERCP, percutaneous transhepatic cholangiography

(PTC), and intraoperative cholangiography (IOC).

ERCP is currently the most routinely used invasive method in the assessment of patients with

presumed CBD stones (Fig. 61-13D). ERCP typically involves an endoscopic sphincterotomy followed by

catheter access of the biliary tree for cholangiogram. ERCP sensitivity has been reported to be between

89% and 93% with a specificity of 100%.82,83 The primary advantage of ERCP is that it allows for

therapeutic intervention if stones are identified. However, since ERCP is an invasive procedure it is

associated with increased morbidity. Complications that can develop after ERCP are pancreatitis (1.3%

to 6.7%), ascending biliary infection (0.6% to 5%), hemorrhage (0.3% to 2%), and perforation (0.1% to

1.1%).72 Due to its invasiveness and associated complications, ERCP should be reserved for those

patients at high risk of having CBD stones.

Figure 61-13. CBD stones are identified (white arrow) on ultrasonography (A), computed tomography (B), MRCP (C), and ERCP

(D).

PTC is comparable to ERCP in terms of success rate (>90% with dilated intrahepatic bile ducts) and

complication rate (∼5%); however, it is typically used in cases in which ERCP was unsuccessful or

aberrant gastroduodenal anatomy is present.

IOC, which can be accomplished laparoscopically or open, is primarily performed as adjunct to

cholecystectomy (Fig. 61-12). IOC has an overall success rate for detecting CBD stones of >95% with a

sensitivity and specificity of 59% to 100% and 93% to 100%, respectively.72 To improve upon its

accuracy, adequate filling of the intrahepatic bile ducts as well as flow of contrast into the duodenum

should be identified and appropriately documented. CBD stones identified on IOC can then be addressed

immediately with a laparoscopic or open CBD exploration or postoperatively via ERCP (discussed

further below). Traditionally, the three primary purposes of performing an IOC were to define biliary

ductal anatomy, identify CBD stones, and serve as an educational tool. There is still considerable debate

on whether or not IOC, more specifically laparoscopic IOC, should be performed routinely versus

selectively during laparoscopic cholecystectomy.84 Advocates argue that asymptomatic CBD stones can

be identified and biliary injuries prevented by performing routine IOC. Proponents of selective IOC

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argue that patients should be risk-stratified and only those patients at considerable risk should undergo

IOC.

Management

Before the laparoscopic era, IOC was routinely performed and identification of CBD stones was

managed immediately with open CBD exploration and T-tube biliary drainage. In the current era,

patients should be appropriately risk-stratified by a thorough history and physical examination with

appropriate biochemical liver profile and imaging adjuncts to assess for possible CBD stones. As

described above, there are many diagnostic options available to the practicing surgeon to assess for CBD

stones and once the diagnosis of CBD stones is established, many options, from a therapeutic standpoint,

are also available to the treating surgeon. These options include (i) endoscopic, (ii) percutaneous, (iii)

laparoscopic, and (iv) open approaches or a combination of any of these techniques.

The choice of the best diagnostic test and ultimate therapeutic intervention is dictated in great part by

the local expertise of the radiologist, gastroenterologist, interventional radiologist, and surgeon at the

treating institution (Algorithm 61-1). Hence, no single standardized approach to the diagnosis and

management of CBD stones has been established. Nonetheless, patients at low to intermediate risk of

CBD stones can be evaluated by less invasive diagnostic methods preoperatively (MRCP or EUS) or

intraoperatively with IOC. Patients at high risk of stones should undergo preoperative ERCP. The

clinical scenario in which the CBD stones present, asymptomatic (incidental stone) versus symptomatic

(cholangitis, biliary pancreatitis, or jaundice), must be put into context and incorporated into the

treatment decision plan.

Algorithm 61-1. Algorithm for the management of common bile duct stones.

Endoscopic Approach

9 ERCP with endoscopic sphincterotomy allows for the diagnosis and treatment of CBD stones. ERCP

with stone extraction is effective in removing stones in 85% to 95% of cases. Stone extraction is

typically accomplished with either a balloon catheter or stone basket. Additional techniques, such as

mechanical lithotripsy, extracorporeal shock-wave lithotripsy, or intracorporeal lithotripsy with laser or

electrohydraulic probes have been used to manage large stones (>15 mm), multiple stones, hard

stones, and/or intrahepatic stones.

Circumstances in which ERCP with sphincterotomy should be considered as the initial therapeutic

intervention are (i) acute cholangitis secondary to distal CBD stone, (ii) gallstone pancreatitis with

biliary obstruction, (iii) in frail medically unfit patients, and (iv) in patients who require

cholecystectomy whom are found to be at high risk or have CBD stones. Additionally, it is

recommended that preoperative ERCP be undertaken if expertise in laparoscopic CBD exploration is not

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available. Preoperative ERCP will allow the treating clinician to identify circumstances (i.e., large

stones, impacted stones, duodenal diverticula, aberrant gastroduodenal anatomy, or bile duct stricture)

in which the patient may not be amendable to endoscopic stone extraction and thus would require either

percutaneous or surgical biliary drainage depending on the available expertise at the treating

institution.

An alternative approach for patients at low or intermediate risk of CBD stones would be to perform

an IOC at the time of cholecystectomy with plans to perform an ERCP either intraoperatively or

postoperatively, if indicated. In the latter situation, this would require another anesthetic intervention

and the surgeon runs the risk that complete bile duct clearance is not achieved endoscopically and

additional procedures would be required.

Percutaneous Approach

From a therapeutic standpoint, simple percutaneous biliary drainage for decompression of an obstructed

biliary tree can be performed safely and efficiently with minimal difficulty. However, percutaneous

transhepatic CBD stone removal is more labor intensive and normally requires multiple sessions after

initial access of the biliary tree. Maturation (at least 7 days) of the transhepatic fistula from the skin to

the bile duct is required prior to attempting percutaneous stone extraction with either balloon catheter

or stone basket. In addition, various procedures, such as mechanical lithotripsy, electrohydraulic

lithotripsy, and extracorporeal shock-wave lithotripsy can then be performed via a percutaneous route

once a mature transhepatic fistula has been established.

Laparoscopic Approach

Concomitant laparoscopic common bile duct exploration (LCBDE) at the time of laparoscopic

cholecystectomy is a method that allows for the complete management of secondary CDB stones and

gallstones in one setting. The main advantage of this approach is that all of the calculous biliary

pathology is addressed with one intervention and under one anesthetic procedure. Studies have shown

that the success rate of this concomitant approach is approximately 94% to 97%, which is similar to

outcomes seen with endoscopic clearance.85,86 The morbidity of a LCBDE (7%) compares favorably to

ERCP. However, LCBDE has yet to gain widespread use, due in great part to the lack of adaptation and

expertise across institutions. LCBDE is ideal for patients with CBD stones incidentally identified at the

time of IOC or those suspected to be at high risk of having CBD stones. LCBDE can be performed via a

transcystic, transcholecystic, or choledochotomy technique. Cystic and CBD diameter and stone size,

location, and number need to be considered when determining the appropriate LCBDE technique.

Laparoscopic transcystic CBDE is the preferred technique and allows for the extraction of small (<1

cm) CBD stones if the diameter and quality of the cystic duct allows. A tortuous or low-inserting cystic

duct, large (>1 cm) stones, and/or common hepatic or intrahepatic stones are relative contraindications

to this technique. This technique avoids the need for a choledochotomy and thus potential need for a Ttube. The transcystic approach involves placement of a guide wire into the CBD through the cystic

ductotomy made for the IOC. With the guide wire in place, a cholangiocatheter can be advanced into

the CBD, which is then saline irrigated in attempt to flush small stones out of the bile duct under

fluoroscopic guidance. An adjunct to this maneuver is to dilate the major papilla with a Fogarty balloon

catheter and/or administer intravenous glucagon prior to flushing the CBD in order to facilitate the

passage of stones. A 3-mm choledochoscope can be passed into the CBD for direct visualization and

stone extraction can be accomplished with the use of a basket. An adjunct to this technique is to dilate

the cystic duct prior to stone extraction. These techniques can also be applied to the transcholecystic

approach, which involves making an incision in the body of the gallbladder. At the completion of either

of these approaches, the cystic duct can be easily closed as it is typically done during laparoscopic

cholecystectomy, and biliary drainage with a T-tube is not necessary.

An alternative laparoscopic approach is to perform a laparoscopic choledochotomy. The advantage to

this approach is that multiple stones, larger stones (>1 cm), or common hepatic or intrahepatic stones

can be removed. In this approach, an anterior longitudinal incision on the CBD below the cystic duct is

made to allow for adequate access but also to avoid unwanted injury to the arterial supply of the bile

duct. Similar techniques of CBDE, discussed previously, can then be undertaken to clear the CBD of

stones. The disadvantage of this approach is that advanced laparoscopic biliary skills are required and

conventionally, the choledochotomy is closed over a T-tube. The potential benefits of leaving a T-tube is

that it allows for the postoperative decompression of the biliary tree, potentially minimizes bile

strictures, and allows for access to the biliary tree postoperatively in case of retained stones

87; this

approach has been associated with a higher morbidity rate when compared to the transcystic approach.

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The increased complication rate is primarily attributed to the placement of the T-tube, and is due to (i)

bile leakage, (ii) wound issues at T-tube insertion site, (iii) dislodgement or displacement of T-tube

leading to biliary obstruction, and (iv) persistent biliary fistula.88 Alternative biliary drainage

approaches, such as intrabiliary stenting, endoscopic nasobiliary drainage, percutaneous transhepatic

biliary drainage, C-tube, and J-tube drainage via the cystic duct after laparoscopic choledochotomy,

have been investigated and have shown promising results.87 Moreover, recent data suggest that routine

biliary drainage with a T-tube is not indicated and primary closure of the CBD is superior to drainage

with a T-tube in regard to postoperative complications and biliary-specific complications.87

Open Approach

In the previous era of open cholecystectomies, open CBD exploration was routinely performed and was

the standard treatment for CBD stones. It was associated with a low morbidity rate and low stone

retention rate (1% to 3%). In the current era of advanced endoscopic, percutaneous, and laparoscopic

approaches, open CBD exploration is infrequently performed. However, when other approaches fail,

open CBD exploration may be necessary. This technique starts with a wide Kocher maneuver to allow

for exposure and palpation of the entire bile duct. The choledochotomy is similar to the one made

laparoscopically and the methods of stone extraction are also similar with the added benefit that digital

manipulation is possible. A 12-French T-tube is usually placed and secured with interrupted sutures (4-0

absorbable sutures). Completion cholangiography is mandatory to assess for CBD clearance and for

leakage around the T-tube. The T-tube is left to gravity bag until postoperative days 3 to 7 when a Ttube cholangiogram is performed and if no obstruction is present the tube can be clamped and

eventually pulled after 4 to 6 weeks once the tract has matured. If retained stones are identified, the

biliary tree can be accessed percutaneously via the T-tube, once the tract has matured, and the stones

can be removed.

Certain patients with impacted stones at the ampulla or with primary bile duct stones, history of

recurrent stones, intrahepatic stones, or a benign distal bile duct stricture may require an open biliary

drainage procedure, such as a transduodenal sphincteroplasty or choledochoduodenostomy or Roux-en-Y

biliary bypass (i.e., choledochojejunostomy or hepaticojejunostomy) as definitive therapy. The

advantage of a choledochoduodenostomy is that endoscopic access to the bile duct is maintained,

however if a side-to-side choledochoduodenostomy is performed, the patient is at risk for developing a

sump syndrome (obstruction of the distal limb of the bile duct with food debris leading to possible

obstruction of the anastomosis, cholangitis, and/or pancreatitis). This syndrome is avoided with a Rouxen-Y biliary bypass, however at the cost of losing access to the bile duct endoscopically.

ETIOLOGY OF ACUTE CHOLANGITIS

Table 61-5 Etiologies of Acute Cholangitis

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