Recurrent bile duct stones after transduodenal sphincteroplasty

Abstract

Background

Transduodenal sphincteroplasty (TDS) offers permanent prophylaxis against further stones in the common bile duct (CBD) by allowing continuous free efflux of bile from the papilla.

Patients and results

In a personal series of 267 consecutive operations, four patients underwent further treatment for recurrent CBD stones during a median follow-up of 12 years. Three of them received Roux-en-Y biliary diversion and had no further symptoms; the fourth patient remains well four years after endoscopic extraction of stones.

Discussion

Recurrent stone formation is rare after an adequate TDS and probably reflects retained food debris within the CBD. Initial treatment may be endoscopic, but biliary diversion is needed for those with recurrent symptoms.

Introduction

Transduodenal sphincteroplasty (TDS) is a thorough, effective, safe and reliable procedure for the treatment of choledocholithiasis. It provides permanent drainage of the biliary tree and should therefore, prevent further bile duct stones ¹,². By definition the anastomosis should be wider than the supraduodenal common bile duct ⁵. Division of the sphincter of Oddi allows duodenal contents to reflux as easily as the free flow of bile. Indeed one proof of an effective sphincteroplasty is the free reflux of barium into the common bile duct (CBD) on a contrast X-ray ⁴, followed by rapid and complete efflux. The free efflux provided by the complete sphincteroplasty should act as permanent prophylaxis against further stones. Nevertheless, in a series of 267 consecutive patients operated on by a single surgeon between 1970 and 1998, there were four who required treatment for further bile duct stones during a median follow-up of 12 years.

Patients

All four patients received an open cholecystectomy with a wide TDS for gallstones in the CBD. In three patients cholangitis and/or jaundice recurred nine months, one year and five years after the primary operation, although initial imaging showed free drainage through the sphincteroplasty and no stones. Ultimately a low CBD stricture developed with stone formation in the dilated biliary tree, and choledochojejunostomy Roux-en-Y was performed 3–13 years after the original TDS. In the fourth patient presentation was delayed for 11 years and the initial treatment of recurrent stones was by endoscopic extraction. Details of these four cases are given below.

Case no. 1

A 50-year-old man underwent open cholecystectomy and TDS for choledocholithiasis. Five years later he developed transient biliary obstruction. Barium meal X-ray at that time provided good views of the duct system without any evidence of CBD stone. He had intermittent right upper quadrant pain for a further seven years when he experienced an attack with jaundice. An ultrasound scan shortly afterwards was normal. A new barium meal showed a dilated supraduodenal biliary tree with relative narrowing of the retroduodenal/intrapancreatic part of the CBD; there was an incidental jejunal diverticulum. The barium cleared rapidly and no stone was seen. Reoperation was carried out 13 years after the primary operation. A small friable stone with vegetable material at the centre was found above the narrowing in CBD. The bile duct was transected, and Roux-en-Y choledochojejunostomy was performed. The patient remains asymptomatic with normal liver function test two years later.

Case no. 2

A 52-year-old woman developed painful intermittent jaundice one year after TDS. Endoscopic retrograde cholangiopancreatography (ERCP) and barium meal studies were normal at that time, and her symptoms and jaundice disappeared spontaneously. Three years later she developed intermittent jaundice again. Barium meal now showed free reflux into the CBD and a stricture 4 cm above the ampullary region, with two stones and dilated ducts above it. A subsequent attempt at dilatation of the stricture by ERCP failed as a 10 mm balloon moved freely in the CBD; however the conglomerate stones broke down very easily. Although removal of the stones alleviated her symptoms, the problems of painful jaundice returned after another year. She underwent transection of the CBD and Roux-en-Y choledochojejunostomy five years after her first operation. Very friable stones were again present. She remains completely asymptomatic eight years later.

Case no. 3

A 52-year-old man developed cholangitis nine months after TDS. Barium meal X-ray showed free reflux of contrast into the CBD, and also free efflux. There was no stone or stricture in the CBD. A small duodenal diverticulum was noted adjacent to the ampulla. Although the cholangitis improved with antibiotics, he suffered recurrent attacks. Eighteen months later ERCP showed retroduodenal stenosis of the CBD with dilated ducts and possible food debris above the stricture. The lower intrapancreatic part of the CBD was also narrow. The patient continued to suffer from recurrent cholangitis. Forty months after the primary operation he underwent transection of the CBD and Roux-en-Y choledochojejunostomy. Infected debris was found in the dilated CBD. Seven years later the patient lives an active, asymptomatic life.

Case no. 4

A 48-year-old woman developed painful obstructive jaundice 11 years after cholecystectomy and TDS for choledocholithiasis. She received ERCP at another hospital with endoscopic sphincterotomy (of the accessory papilla) and extraction of stones from the CBD via TDS. Four years after this procedure she remains asymptomatic.

Discussion

First recorded by McBurney in 1898 ⁴ transduodenal sphincteroplasty is one of several ways of achieving free drainage of CBD. The choice of permanent drainage procedure for the CBD should be tailored to the specific problem, but each operation has its own indications and contraindications ¹,⁵. Postoperative complications include acute pancreatitis, cholangitis, haemoperitoneum, subphrenic abscess, and biliary fistula, plus inadequate sphincteroplasty with retained stones ¹,²,³,⁶.

Recurrent common bile duct stones following adequate sphincteroplasty are very rare, but the definition of recurrent stones is unclear. Madden ⁷ suggested an arbitrary time division at two years after the primary operation: stones diagnosed within two years were ‘residual’ and stones diagnosed after two years were ‘recurrent’. He acknowledged that this classification was empirical not factual. We accept this pragmatic approach. One of our patients (case no. 3) developed symptoms as early as nine months after TDS, despite completion cholangiography being clear at the end of the operation.

Baker and colleagues ⁸ reported one similar case among 56 patients who had undergone either sphincterotomy or sphincteroplasty, but they did not state which procedure this single patient had received. Stefanini and colleagues ¹ reported nine patients who required further operation for residual or recurrent stones among a group of 712 who had received TDS; they failed to mention how many stones were truly ‘recurrent’ and how many patients had had a complete sphincteroplasty. In three of our four patients, sphincteroplasty was deemed complete as evidenced by the free entry and exit of barium to and from the CBD.

Another means of achieving permanent drainage of the CBD is by side-to-side choledochoduodenostomy, but sump syndrome and/or cholangitis may complicate this procedure in 5% of patients ⁹. A meta-analysis of reported series ⁵,¹⁰,¹¹,¹²,¹³,¹⁴,¹⁵,¹⁶ (Table 1) gives a rate of 29/937 (3.1%) for sump syndrome and/or recurrent cholangitis and an operative mortality rate of 26/937(2.7%) for choledochoduodenostomy. In our series of TDS, the recurrent cholangitis rate was 4/263 (1.5%) and the operative mortality rate was 4/263 (1.5%). The recommended treatment of sump syndrome is endoscopic sphincterotomy, though this procedure has its own morbidity and a restenosis rate as high as 19% ¹⁷, necessitating further papillotomy. By contrast the TDS stoma provides dependent drainage and very seldom requires reintervention.

Table 1. Incidence of sump syndrome (SS) and perioperative death following choledochoduodenostomy.

Author	Journal/Year	No. of patients	SS/cholangitis n(%)	Operative death n(%)
Rutledge	Ann Surg 1976	13	1 (7.7)	0
Rizzuti	Am Surg 1987	75	0	1 (1.3)
Birkenfeld	Am Surg 1987	55	0	1 (1.8)
Baker	Ann RCS Engl 1987	190	6 (3.3)	10 (5.3)
Parilla	Br J Surg 1991	225	9 (7.1)	4 (1.8)
Deutsch	Eur J Surg 1991	126	6 (5.8)	5 (4)
Panis	Surg Gynecol Obst 1993	58	6 (10.3)	2 (3.8)
de Almeida	HPB Surg 1996	125	3 (2.7)	2 (1.6)
	Total	867	31 (3.5)	25 (2.9)

The aetiology of recurrent choledocholithiasis after TDS is likely to be retention of food particles in a stagnant biliary tree. Migration of food debris can occur through an intact sphincter of Oddi and cause stones in the CBD ¹⁸. Likewise, food debris, retained in the CBD after entry through the stoma, is recognised as the cause of ‘sump syndrome’ following choledochoduodenostomy ¹⁹.

There can be no doubt that duodenal peristalsis produces very easy reflux into the CBD through an adequately performed sphincteroplasty and that this may include food debris ¹⁰. Most of this chyme escapes back freely into the duodenum, although particulate food may well linger or be trapped above any relative narrowing (Figure 1), allowing it to act as a nidus for conglomerate stones. The friability of these stones seems likely to explain the recurrent transient symptoms in our patients. Such stones may also cause local inflammation, thereby aggravating stricture formation and further obstructing their drainage and thus predisposing these patients to cholangitis and increased narrowing of the lower CBD, i.e. there is a vicious cycle. It is essential to create a large sphincteroplasty aperture so that the healing of the suture line by scarring does not result in stricture, and the same applies to choledochoduodenostomy. Our own practice has been to make the sphincterotomy cut long enough to extend through the full thickness of the duodenal wall (to ensure complete sphincter division), and to create a sutured opening more than two and a half times the size of the CBD at this level. This technique explains why a 10 mm balloon was not arrested at this point in case no. 2. Reflux cholangitis seems to be rare after sphincteroplasties, provided that a large enough stoma has been made ²⁰. Perhaps it is inflammation within the head of the pancreas compressing the CBD that initiates the progressive cycle of food retention, cholangitis and then further narrowing.

Figure 1. .

Barium meal x-ray. Arrow showing patent sphincteroplasty of the CBD with relative narrowing above (case no. l).

Although TDS is an effective and safe operation, there seems to be no randomized study available at present to compare it against different procedures for permanent biliary drainage. Where it is available, endoscopic sphincterotomy has become the norm for treating CBD stones, yet TDS has proved safe and effective in our hands and remains a reliable option for surgeons in the developing world. Common bile duct stones can recur despite adequate TDS but rarely. Initial treatment by endoscopic stone extraction will also help to delineate any ductal pathology; barium studies (especially with gas insufflation) give valuable extra information. Persistent symptoms with associated duct stricture are best treated by operative division of the CBD and Roux-en-Y biliary diversion.