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OPERATIVE CHOLANGIOGRAPHY by A 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.
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