Percutaneous Extraction of Retained Gallstones

A 10 year single centre experience of percutaneous and endoscopic extraction of bile duct stones with T tube in situ

A non-randomised single centre study of 226 consecutive patients referred over 10 years with retained common bile duct stones and a T tube in situ or a cholecystostomy tube are reported. Percutaneous extraction was attempted in 204 and endoscopic extraction in 68 patients. Percutaneous clearance was achieved in 158 (77.5%) patients and endoscopic clearance in 52 (76.5%) patients. Six of 153 (3.9%) patients followed after percutaneous treatment suffered major complications (pancreatitis, cholangitis, or tract perforation). Three of 67 (44%) patients followed after endoscopic treatment suffered major complications (pancreatitis, cholangitis, or bleeding). When the initial method of treatment failed, the alternative was used, resulting in an overall success rate of bile duct clearance of 94.3%. It is concluded that percutaneous and endoscopic methods of bile duct clearance in patients with a T tube in situ are equally effective, carrying similar complication rates. This study has helped to clarify the indications and efficacy of these alternative treatments.

Bypass of obstructing bile duct calculus by an endoprosthesis inserted via a T-tube track

A surgically introduced biliary endoprosthesis in a patient with a cholangiocarcinoma prevented extraction of a calculus in the lower common bile duct through a T-tube track. The problem was solved by the introduction of a second endoprosthesis across the ampulla of Vater through the T-tube track in order to prevent obstruction of the common bile duct by the calculus.

Non-invasive treatment for retained common bile duct stones in patients with T tube in situ: saline washout after intravenous ceruletide

The combination of ceruletide-induced relaxation of the sphincter of Oddi plus flushing with saline has recently been proposed as a novel procedure for the treatment of residual common bile duct (CBD) stones. In this study we have administered intravenous ceruletide (2 ng kg-1 body weight min-1 for 1 h) plus intraductal saline (800-3000 ml, infused at a rate that kept biliary pressure below 30 cmH2O) to a group of 14 patients. The treatment induced the passage of residual stones in 11 subjects (79 per cent) with complete clearance in 7 (50 per cent). The majority of the cleared concretions (11/15) had a diameter less than 10 mm. No severe side-effects were recorded during the treatment. Four of the seven subjects who exhibited incomplete CBD clearance underwent a short cycle of mono-octanoin administration in order to reduce the size of residual radiolucent stones. This course of treatment was followed by another attempt with intravenous ceruletide and saline washout which gave a successful response in an additional three cases. These data indicate that the combination of ceruletide and flushing is a safe and inexpensive method for treatment of residual stones. The procedure is feasible for both radiolucent and radio-opaque stones and is mainly eligible for small concretions of diameter less than 10 mm. Larger (greater than 10 mm) radiolucent stones may be partially dissolved with mono-octanoin and then eliminated by the washout technique.

Endoscopic sphincterotomy for retained common bile duct stones in patients with T-tube in situ in the early postoperative period

We report on thirty-nine patients who underwent endoscopic sphincterotomy (ES) and stone extraction for retained common bile duct calculi with a T-tube in situ. Sixteen of the patients had undergone unsuccessful attempts at removal by flushing or dissolution by cholesterol solvents. A total of 76 stones were present: 53 distal to the T-tube and 23 proximal to the T-tube. ES and clearance of the common bile duct was achieved in 37 patients (95 per cent) and complications occurred in three patients (7.7 per cent). This method is an effective and relatively safe method in the early postoperative period allowing rapid treatment during the same admission as for the original operation and early hospital discharge.