388 .. . Postgrad Med J: first published as 10.1136/pgmj.32.370.388 on 1 August 1956. Downloaded from

OPERATIVE CHOLANGIOGRAPHY By A. W. NURICK, F.R.C.S. Late Senior Registrar, The Middlesex Hospital

There is no doubt that stones may be left behind Exploration of the common bile duct does not in the common bile duct after operation. Estimates necessarily mean that it has been completely of the incidence of this complication vary widely cleared of stones and the practice of T tube drain- and the following table shows some of the pub- age of the duct has been generally adopted because lished figures: of the danger of intraperitoneal leakage of bile from the suture line should the duct be closed and INCIDENCE OF RESIDUAL STONE IN THE COMMON DUCT obstruction to the flow of bile into the duodenum Authority Incidence develop. It is customary, before removing a T tube, to Mallet-Guy and Gangolphe (I953) .. 6.9% This Demel (1952) ..... 5.5% perform cholangiography. investigation is Johnston, Waugh and Good (1954) . 8% usually responsible for making the diagnosis of a Buxton and Burk (1948) . .. 5.9% stone in the common duct which has been missed Glenn (I952) ...... 7% at operation. Post-operative cholangiography is McKittrick and Wilson (1949) .. 2% about io after and whenProtected by copyright. . days .. performed operation Bruce (I954) .. 2.5% Hicken, McAllister and Call (I954) . 20% it demonstrates a residual stone the surgeon is Pribram (1947) .. 2.. 1I6-25% presented with information which would have been both more useful and more welcome had it been It is difficult to interpret the higher figures except available while the abdomen was still open at the as a reflection on the frequency and thoroughness original operation. of duct exploration or on the experience of the Hicken, McAllister, Franz and Crowder (1950) surgeon. Hicken, McAllister and Call (I954) have traced the development of post-operative found that in their collected series of 550 opera- cholangiography 'since the .accidental demonstra- tions with residual stones in IIo (20 per cent. tion by Reich in 1918 of the biliary tract after the incidence) the chance of leaving a stone increased injection of' petrolatum and barium paste' into a tenfold when the surgeon was inexperienced. The persistent sinus. Mirrizi (I932) seems to have been overall incidence of residual stone is probably in the first to take the logical step of performing the of lower in the at the time of The neighbourhood 5 per cent.; cholangiography operation. http://pmj.bmj.com/ hands of experts, higher in the hands of those less early operative cholangiograms often failed to out- accustomed to biliary surgery. line the whole biliary tract because the medium The possible causes of residual stones in the used was lipiodol, which may pool and globulate common bile duct are two: failure to explore the in the ducts because it will not mix with bile. The "duct and failure, on exploration, to remove all introduction of a' water-soluble organic iodine stones. The third possibility of stone formation in compound, diodone, 35 per cent. or 50 per cent., the common duct after cholecystectomy does exist, has greatly improved the quality of cholangio- but the majority of stones found in the common grams (Hicken et al., 1950). on September 28, 2021 by guest. duct after cholecystectomy have been there since Although post-operative cholangiography is now the original operation. a routine procedure, cholangiography during It is not within the scope of this paper to operation has not achieved much popularity out- examine the indications for exploration of the side a few centres. Its chief advocates have been common bile duct, f6r they are widely known Mallet-Guy (1947, 1952) in France, Hicken and (Allen, I936; Lahey, 1938; Glenn, 1952). If his co-workers (I949) in America, Milbourn (I949) 'these indications are recognized and conscientiously and Norman (I951:) in Sweden, and McNeill Love observed, few stones should be left behind as a (1952) in this country. result of failure to open the duct; by .the same Cholangiography may be performed as a diag- token a number of fruitless explorations are bound nostic measure before duct exploration, by means to be performed. of a cannula or polythene tube inserted into the August 1956 NURICK : Operative Cholangiography 389

cystic duct, or by direct injection of diodone into able to tell whether a filling defect is an air bubble Postgrad Med J: first published as 10.1136/pgmj.32.370.388 on 1 August 1956. Downloaded from the common duct. Diagnostic cholangiography or a stone by its behaviour when the patient's causes little delay in the operation, for the surgeon position is altered. It is not practicable to perform can remove the gall bladder while the films are operative cholangiography under screen control being developed. Post-exploratory or control and few hospitals have the necessary equipment; cholangiography is performed via a T tube sutured the alternative used is to expose a series of films firmly into the common duct so as to prevent any after injection of increasing volumes of diodone. leakage; there is an inevitable delay in the opera- Errors of technique can result in misleading tion while the films are developed. cholangiograms, air bubbles may simulate stones, The theoretical grounds for advocating chol- movement may occur during exposure of the films, angiography at the time of operation rather than the shadow of the duct may be superimposed on io days later are unquestionably sound, but it is the vertebral column and diodone, which has apparent from some of the published work that entered the duodenum, may overlie and obscure the procedure is not absolutely reliable. ' False the lower end of the common duct where stones positive' cholangiograms may be obtained which are so frequently to be found. False negative indicate a stone when none is present and ' false cholangiograms can also occur because the density negative' cholangiograms may be obtained which of the medium may completely hide stones, suggest the duct is clear of stones when they are, especially when the duct is dilated. This has been in fact, present. Reviewing 406 cases, Mixter, shown experimentally by Gius, Tidrick and Hickey Hermanson and Segel (I95 ) found that in I 3 (I954). cases where operative cholangiography was fol- Operative cholangiograms may be difficult to lowed by duct exploration there were five ' false interpret. The normal duct is not dilated, free positive' and nine ' false negative' cholangio- from filling defects and a small injection of diodone grams, a total error of 12 per cent. in the procedure. enters the duodenum easily. Stones in the common Operative cholangiography after exploration of the duct reveal their one or duct in 146 cases revealed unsuspected residual may presence by any any Protected by copyright. calculi in 19 (13 per cent.), but there were also combination of the following signs: a filling defect, seven patients in this group (4.9 per cent.) with failure or poor entry of diodone into the duodenum, apparently normal post-exploratory cholangio- a dilated duct, excessive filling of the smaller intra- grams who were subsequently proved to have hepatic ducts, irregularity or abrupt truncation of residual stones in the common duct at operation the lower end of the duct. or post-mortem. Kantor, Evans and Glenn (1955) Cholangiograms performed after duct explora- reported I58 cases with 9 per cent. residual stones tion should theoretically give the most useful in- despite operative cholangiography. Hughes (i955) formation to the surgeon, but these cholangio- had three false negative and four false positive grams are often the most difficult to interpret. It cholangiograms in 91 cases, an error of 8 per cent. may be that instrumentation of the lower end of In a personal experience of 65 operative cholangio- the duct sets up some local spasm, for it is not grams where the duct was explored there were nine uncommon to find that the diodone fails to enter false and one false the duodenum even though instruments can be positive negative cholangio- http://pmj.bmj.com/ grams, an error of 5 per cent. passed through the sphincter. This effect may be It seems, therefore, that the chance of getting a seen even after the duodenum has been opened and misleading operative cholangiogram is as great, if the sphincter of Oddi divided so that there can be not greater, than the chance of leaving a stone in no question about the patency of the lower end of the duct after exploration. Although it is true that the common duct. It is also difficult to exclude air unexpected stones in the duct may be detected and bubbles and to avoid leakage of diodone in post- removed as a result of operative cholangiography, exploratory cholangiograms. it is also true that misplaced faith in an apparently The incidence of false negative and false positive on September 28, 2021 by guest. normal cholangiogram may result in a stone being cholangiograms can be diminished by careful left behind. attention to details of technique. Air bubbles can One explanation why operative cholangiography be excluded by filling all tubing with saline and is less accurate in the diagnosis of common duct by aspirating before injecting the diodone. Tilting stones than post-operative cholangiography lies in the operating table laterally through I5° to the the difference between the two techniques. Post- right will throw the shadow of the common duct operative cholangiography is performed under clear of the vertebral column. Serial films exposed fluoroscopic control. The radiologist is able to after injection of I-3 ml., 6-Io ml. and 15-20 ml. position the patient and fill the ducts so as to get help to show the lower end of the duct clearly. the best possible pictures; he can also observe the Control of the patient's respiration during flow of diodone into the duodenum and-may be exposure of the films is essential. By these means, 390 POSTGRADUATE MEDICAL JOURNAL August 1956 technically satisfactory films can be obtained in a dilated sphincter into the duodenum. This view isPostgrad Med J: first published as 10.1136/pgmj.32.370.388 on 1 August 1956. Downloaded from high proportion of cases. supported by the experience of Brush, Powka, It is essential that, in addition to having good Damazo and Whitcomb (I955), who do not use X-ray films, the surgeon be familiar with the radio- operative cholangiography. They found that no logical appearance, normal and abnormal, of the second operations for residual stone were required biliary tract. Even when these conditions are ful- in I98 cases where the sphincter of Oddi was filled, there remains a margin for error in the ex- dilated, whereas in a control series of 250 explora- amination itself or in the interpretation of the tions where the sphincter was not dilated there films. The result of this error is that a normal were o second operations for residual calculi diagnostic operative cholangiogram is not neces- (4 per cent.). sarily a guarantee that the duct is free from stones and consequently does not excuse the surgeon from Conclusions exploring the duct if any of the clinical or operative I. The value of operative cholangiography in indications for exploration are present. A normal the diagnosis of residual stone in the common bile control cholangiogram after exploration ofthe duct, duct is diminished by the occurrence of false likewise, does not necessarily guarantee that the negative and false positive results. duct is clear. A false positive cholangiogram is a 2. The use of operative cholangiography does nuisance, for it may lead to an unnecessary explora- not necessarily lessen the incidence of residual tion of the common duct, but a false negative common duct stone. cholangiogram is a menace, for it may result in a 3. The results of careful instrumental explora- second operation for a residual stone. tion of the common bile duct, including lavage and The unreliability of operative cholangiography dilatation of the sphincter of Oddi, can be has influenced some authorities against its use. excellent. Waugh, Walters, Gray and Priestley (1952) con- sider it unnecessary and Maingot (1952) considers BIBLIOGRAPHY it cumbersome, unnecessary and misleading. These ALLEN, A. W. (I936), Surg. Gynec. Obstet., 62, 347. Protected by copyright. facts do not, however, mean that operative chol- BRUCE, J. (1954), Trans. Med. Soc. Lond., 71, 19. is devoid of value. who has BRUSH, B. E., and POWKA, J. L. angiography Nobody DAMAZO, F., and WHITCOMB, J. (1955), Arch. Surg. (Chicago), had the experience of demonstrating an unsus- 70, 766. residual calculus in the common duct BUXTON, R. W., and BURK, L. B., JUN. (1948), Surgery, 23, 760. pected by DEMEL, R. (1952), Arch. Klin. Chir., 271, 302. operative cholangiography and of removing the GIUS, T. A., TIDRICK, R. T., and HICKEY, R. C. (1954), stone before closing the abdomen can question the Surgery, 36, 460. value of on such occasions. GLENN, F. (1952), Surg. Gynec. Obstet., 95, 431. cholangiography HICKEN, N. F., CORAY, Q. B., and FRANZ, B. (1949), Surg. Whether it reveals stones or not, cholangiography Gynec. Obstet., 88, 577. HICKEN, N. F., McALLISTER, A. J., FRANZ, B., and will always show the anatomy of the duct system CROWDER, E. (1950), Arch. Surg. (Chicago), 60, 1102. and will demonstrate any variation from the normal HICKEN, N. F., McALLISTER, A. J., and CALL, W. D. (I954), and far more Ibid., 68, 643. (Hicken, Coray Franz, 1949) quickly HUGHES, E. S. R. (I955), Med. J. of Australia, I, 820. and certainly than dissection will. It must not be KANTOR, H. G., EVANS, J. A., and GLENN, F. (I955), Arch. that has the Surg. (Chicago), 70, 237.

forgotten cholangiography played http://pmj.bmj.com/ in to the attention of LAHEY, F. H. (I938), Amer. J. Surg., 40, 209. major part bringing surgeons LOVE, R. J. McNEILL (I952), Brit. J. Surg., 40, 214. the ease and frequency with which stones may be MAINGOT, R. (I952), Ann. R. Coll. Surg. Eng., 10, 97. left behind in the common duct. MALLET-GUY, P. (1947), 'La Chirurgie biliaire sous controle Manometrique et Radiologique per operatoire,' Masson et Cie. The hope that operative cholangiography would Paris. reduce substantially the number of MALLET-GUY, P. (1952), Surg. Gynec. Obstet., 94, 385 unnecessary MALLET-GUY, P., and GANGOLPHE, M. (x953), Mem. Acad. duct explorations and eliminate the risk of residual Chir., 79, 6o. stones has not been fulfilled. The successes of the McKITTRICK, L. S., and WILSON, N. J. (1949), California Med., 71, I32 show that it has but on September 28, 2021 by guest. procedure great potentialities, MILLBOURN, E. (I949), Acta. Chir. Scand., 99, 285. small stones or even large stones in dilated ducts MIRIZZI, P. L. (1932), Bol. Y. Trab. Soc. de Cir. de Buenos Aires, not be demonstrated. In a recent x6, 1133. may editorial, MIXTER, C. G., HERMANSON, L., and SEGEL, A. L. Walters (I955) states that after careful instrumental Ann. Surg., 134, 346. (I951), exploration of the common duct (through an in- NORMAN, O. (I95I), Acta. Radiol. Suppl., 84. cision in its wall and PRIBRAM, B. O. C. (1947), Surgery, 22, 8o6. not through the stump of the REICH, A. (1918), J.A.M.A., 71, I555. cystic duct), repeated lavage and dilatation of the WALTERS, W. (I955), Arch. Surg. (Chicago), 70, 323. of Oddi the stones liable to be left WAUGH, J. M., WALTERS, W., GRAY, H. K., and sphincter only PRIESTLEY, J. T. (1952), Proc. Staff Meet. Mayo Clin., 27, behind are small ones which can pass through the 578.