S Mahmud1, I McGlinchey, H Kasem, A H Nassar. 1. Department of Surgery, Vale of Leven District General Hospital, Alexandria, Dunbartonshire, Scotland, 683 OUA, UK.
Abstract
BACKGROUND: Retained common bile duct (CBD) stones pose an occasional problem following ductal exploration, in spite of completion cholangiography or choledochoscopy. We present a method for treating retained stones in the Radiology Department by biliary lavage via a transcystic tube (TCT) or a T-tube, after intravenous administration of glucagon. METHODS: A TCT or T-tube is inserted following CBD exploration for multiple intrahepatic stones or when stones are fragmented to facilitate removal or flushing into the duodenum. A tube cholangiogram is performed on the 1st postoperative day. If any retained stones are encountered, 1 mg glucagon is administered intravenously and saline irrigation through the tube is done under fluoroscopic control, allowing the stone to pass to the duodenum. The cholangiogram is repeated 10-14 days later, before removing the tube. RESULTS: In case 1, transcystic CBD exploration was performed. Two stones were crushed and flushed into the duodenum. TCT cholangiography the following day. showed a 5-6-mm fragment causing complete obstruction. Following the use of glucagon and irrigation, the stone was observed passing into the duodenum, causing a brief mild episode of pain. In case 2, laparoscopic choledochotomy was performed to remove seven large stones. Completion choledochoscopy was satisfactory. T-tube cholangiography identified a small stone in the CBD, which was cleared with the help of glucagon. CONCLUSION: The current standard treatment for retained stones is endoscopic sphincterotomy. This is associated with morbidity, mortality, and significant additional cost. This new technique is a simple and safe alternative for retained CBD stones, most of which as small stones or fragments. Because glucagon causes intense relaxation of the sphincter of Oddi, the procedure should not take much longer than a routine tube cholangiogram. The safety of glucagon makes it possible to repeat the procedure if necessary.
BACKGROUND: Retained common bile duct (CBD) stones pose an occasional problem following ductal exploration, in spite of completion cholangiography or choledochoscopy. We present a method for treating retained stones in the Radiology Department by biliary lavage via a transcystic tube (TCT) or a T-tube, after intravenous administration of glucagon. METHODS: A TCT or T-tube is inserted following CBD exploration for multiple intrahepatic stones or when stones are fragmented to facilitate removal or flushing into the duodenum. A tube cholangiogram is performed on the 1st postoperative day. If any retained stones are encountered, 1 mg glucagon is administered intravenously and saline irrigation through the tube is done under fluoroscopic control, allowing the stone to pass to the duodenum. The cholangiogram is repeated 10-14 days later, before removing the tube. RESULTS: In case 1, transcystic CBD exploration was performed. Two stones were crushed and flushed into the duodenum. TCT cholangiography the following day. showed a 5-6-mm fragment causing complete obstruction. Following the use of glucagon and irrigation, the stone was observed passing into the duodenum, causing a brief mild episode of pain. In case 2, laparoscopic choledochotomy was performed to remove seven large stones. Completion choledochoscopy was satisfactory. T-tube cholangiography identified a small stone in the CBD, which was cleared with the help of glucagon. CONCLUSION: The current standard treatment for retained stones is endoscopic sphincterotomy. This is associated with morbidity, mortality, and significant additional cost. This new technique is a simple and safe alternative for retained CBD stones, most of which as small stones or fragments. Because glucagon causes intense relaxation of the sphincter of Oddi, the procedure should not take much longer than a routine tube cholangiogram. The safety of glucagon makes it possible to repeat the procedure if necessary.
Authors: William W Hope; Robert Fanelli; Danielle S Walsh; Vimal K Narula; Ray Price; Dimitrios Stefanidis; William S Richardson Journal: Surg Endosc Date: 2017-03-31 Impact factor: 4.584