Surgical Significance of Dilatation of the Common Bile Duct--with Special Reference to Choledocholithiasis

Masao NAGASE, Yorinori HIKASA, R.D. SOLOWAY,* Hiroshi TANIMURA, Motoichi SETOYAMA, Sumio MUKAIHARA and Hitoshi KATO

ABSTRACT: Diameter of the common bile duct was measured in 3,119 patients who underwent pr imary operation for gallstones, during the period from 1975 to 1978. Although dilatation of the common bile duct was most marked in patients with bilirubin stones in the bile duct alone, dilatation was also observed in patients with cholesterol stones in the gallbladder alone. Drip infusion eholangiograms of 84 healthy patients showed that the common bile duct dilated in parallel with aging. A review of patients with congenital choledochal cysts reported in the literature in J a p a n revealed that few had gallstones. Thus, it was difficult to determine whether common bile duct di- latation was the cause or result of gallstones, and it was suggested that the so- called drainage operation such as choledochoenterostomy should be done only under strict indications.

KEY W O R D S : bile duct stone, bilirubin stone, cholesterol stone, congenital choledochal cyst, choledochoenterostomy.

INTRODUCTION

T h e r e are discrepancies regarding the significance of common duct dilatation in surgery for gallstones. Points of view extend from those who regard the dila- tation as a cause of formation of so-called stasis s tones--pr imary in common duct and who advocate choledochoenterostomy in order to prevent recurrence of gallstones, to those who consider it to be secondary to the presence of gallstones and who undertake external choledochal drainage only.

The aim of our study was to review the degree of common duct dilatation

The Second Department of Surgery, Kyoto University, Faculty of Medicine

*Visiting Scholar at Kyoto University, on leave from the University of Pennsylvania School of Medicine and supported in part by U.S. National Institutes of Health Grant AM 16549.

in patients undergoing surgery for gall- stones, to provide objective data as to whether the common duct dilatation can be referred to as an indication for per- forming drainage operations.

METHODS

The diameter of the common bile duct just above the first portion of the duo- denum was measured by using calipers, during operation, in 3,119 patients who underwent pr imary operation for gall- stones at the Second Surgical Department of Kyoto University and 37 affiliated hospitals during the period from 1975 to 1978. The kinds and sites of gallstones, ages of the patients and modes of opera- tions were also recorded. The diameter of the common duct of 84 persons having an intact biliary tract was measured at its widest portion demonstrated by drip infusion cholangiography. Seven adult

JAPANESE JOURNAL OF SURGERY, VOL. |0, No. 4, pp. 296-301, 1980

Volume 10 Number 4 Dilatation o f the common bile duct 297

Type Site

under

39

40--59

o v e r ~ 6 0 ~ )

C Cholesterol stones GB : Gallbladder B Billrubin stones BD : Bile duct Bl Black stones

Fig. 1. Types and sites of gallstones at different ages.

patients with congenital choledochal cysts on whom the authors had operated on during the last 14 years were reviewed with special attention to coexistence of gallstones. Also reviewed were 119 cases of congenital choledochal cysts reported in the literature in Japan from 1950 to 1966 which contain clear description concerning coexistence of gallstones.

RESULTS

Kinds and sites of gallstone distributed according to the patients age are shown in Fig. 1 demonstrate the increasing incidence of bilirubin stones and bile duct stones with advancing age. The bile duct here was the entire biliary tract other than the gallbladder and cystic duct. The diameter of the common duct of patients with bile duct stones, with or without gallbladder stones, in each decade of age as shown in Table 1 indicates that most patients had a slight enlarge- ment (1-2 cm) which did not change with age. However, there was a progres- sive increase in the proportion of patients

T a b l e 1. Diameter of the common bile duct of patients with bile duct stones with or without gallbladder stones in each decade of age

Age -29 30-38 40-49 50-59 60-69 70- Total

Diameter of the common bile duct less than l cm 4(19%) 12(17%) 19(17%) 26(14%) 28(13%) 1 4 ( 8 % ) 103(13%) 1-2 cm 13(62) 47(67) 67(58) 109(60) 124(56) 87(51) 447(57) more than 2 cm 4(19) 11(16) 29(25) 47(26) 71(32) 68(40) 230(30)

Total 21(100) 70(100) 115(100) 182(100) 223(100) 169(100) 780(100)

Numerals in parenthese indicate per cent.

Table 2. Comparison of the common bile duct diameter in patients with cholesterol or bilirubin bile duct stones with or without gallbladder stones.

Diameter of the common bile duct less than 1 cm 1-2 cm more than 2 cm Total

Stone group Cholesterol Bilirubin

71(21.%) 204(62.0%) 54(16.4%) 329(100%) 28(6.4%) 235(54.0%) 172(39.6%) 435(100%)

298 Nagase et al.~ Jpn. J. Surg. Dec. 1980

Table 3. Diameter of the common bile duct of patients with bilirubin stones in the bile duct without galbladder stones in each decade of age.

Age -29 30-39 40-49 50-59 60-69 70- Total

Diameter of the common bile duct less than 1 cm 0 0 2(9%) 0 5(7%) 4(6%) 11(5%) 1-2 cm 0 6(55%) 13(57) 29(64%) 43(54) 33(48) 124(54) more than 2 cm 2(100%) 5(45) 8(35) 16(36) 31(39) 31(46) 93(41)

Total 2(100) 11(100) 23(100) 45(100) 79(100) 68(100) 228(100)

Tab le 4. Diameter of the common bile duct of patients with cholesterol stones in the bile duct without gallbladder stones in each decade of age.

Age -29 30-39 40-49 50-59 60-69 70- Total

Diameter of the common bile duct less than 1 cm 1-2 em more than 2 em

0 0 2(18%) 1(7%) 0 0 3(6%) 0 4(8%) 6(55%) 11(73%) 9(75%) 1(25%) 31(63) 2(100%) 1(20) 3(27) 3(20) 3(25) 3(75) 15(31)

Total 2(100) 5(100) 11(100) 15(100) 12(100) 4(100) 49(100)

with a duc t grea ter than 2 cm in dia- meter ( X 2 < 2 5 . 8 , p < 0 . 0 0 6 ) , mlm 0

The pat ients wi th bile duc t stones were d iv ided into cholesterol and b i l i rub in 8 stone groups for compar i son (Tab le 2). Bi l i rubin stone pat ients had more marked

6 d i la ta t ion (X2=67 .7 , p < 0 . 0 0 0 1 ) . How- ever, 16.4 per cent of cholesterol pat ients also had m a r k e d d i l a t a t ion ( larger than 4 2 cm in d iameter ) . T a b l e 3 indicates tha t pat ients having b i l i rub in stones in 2 the bile duc t bu t none in the ga l l b l adde r had m o d e r a t e or m a r k e d d i l a t a t ion in 0 a lmost the same f requency (35-46 per cent) in each decade of age. The two pat ients younger than 29 years had marked cystic d i la ta t ion . T a b l e 4 shows tha t only 49 pat ients h a d cholesterol

GO �9 0 o o 0 �9 Oeo o o �9

�9 O e o �9 e o o o �9 OO �9

Y=0.03X+6.01 T82=2.11 P<0.05

20 40 60 80 age

Fig. 2. Change in the largest common bile duct size with age in healthy persons.

stones in the bile duc t a lone and had a of 84 hea l thy persons and was p lo t ted lesser degree of d i l a t a t ion than d id accord ing to the age (Fig. 2). The b i l i rubin stone patients , bu t the difference c o m m o n duc t of hea l thy persons became between the two stone groups was not sl ightly d i l a ted wi th aging. However , significant. Two pat ients younge r than the mean d i ame te r a t age 20 was 6.8 m m 29 years h a d m a r k e d cystic d i la ta t ion , and a t age 70 was 9 . 2 m m . The d i ame te r of the c o m m o n duc t was The cl inical character is t ics of seven measured on dr ip infusion cho lang iograms adu l t pat ients wi th congeni ta l choledo-

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Dilatation o f the common bile duct

Table 5. Adult patients with congenital choledochal cysts (Kyoto University, 1965-1978)

299

Configuration The largest Case Age Sex Pregnancy of the diameter of Gallstones

biliary tracts the cysts

1 27 F 3M ~ , V / 7 cm

2 40 F (--) .~3( 5cm

3 25 F 3M //1~v~ ~ o o ~8~ 7 cm none

h

4 26 F 6M ~ ' ~ / / ~ 13 cm

5 27 F (--) ~oonl 4 cm

Y 6 24 F (--) ~ - ~ ) 7 cm none

7 54 F (--) 4 / ~ ~ 5cm none

none

sand in the gallbladder

20 cholesterol stones in the cyst and cholester- osis of the gallbladder

2 cholesterol stones in the cyst and cholester- osis of the gallbladder

N o .

0 100 0 i 0 5

[Z3Patients with congenital choledochal cysts

~Patients with gallstones

18 .~. 17 13 N ~ V~

. . . . R N • A • 10 15 20 25 30 35 40 45 50

Y.O.

Fig. 3. Incidence of gallstones in the 119 patients with congenital choledochal cysts (Alonso-Lej Type I) reported in literature in Japan from 1949 to 1966.

chal cysts, whom the authors treated during the last 14 years are summarized in Table 5. One patient had bilirubin stones and two had cholesterol stones, while no stones were found in the other four. In Fig. 3 the incidence of gall- stones was indicated in 119 patients with congenital choledochal cysts who were reported in Japanese literature from 1949 to 1966 and which contained clear descrip- tions

gallstones. Among 35 patients over 20 years, two had bilirubin stones in the biliary tracts.

DISCUSSION

In contrast to cholesterol stones which are formed almost exclusively in the gallbladder, bilirubin stones can be formed not only in the gallbladder but also in the bile duct. 4 Madden et al. emphasized the surgical significance of pr imary common duct stones and advocated including choledochoentero- stomy to prevent recurrence of common duct stones, s However, they did not mention why they thought the stones formed primarily in the common duct. Matsumoto et al. reported on 88 patients with diffusely dilated, fusiform or cylindrical common duct, which they called "adult type of congenital cystic dilatation of the common bile duct".

concerning the coexistence of They also recommended choledochoentero-

300 Nagase et al. Jpn. J. Surg. Dec. 1980

~ Normal size ~.+ + ~ intrahepatic ducts . "l f l ~L , ~ ' B ~ W ~ -t'~

I l # f "~-- ~ [~Nj +d - '~ ~ Di l a t a t i on of ' ~ ~ "

\ ~ " ~ L ) " ( / ff/r~intra-and M j ' ~ - . a ~ ~kx A~ I ~l extrahepatic ~

~ ~t~ ~1 ducts ~

~ li' ~----I ~ ~] Chronic ~ ' 1 [ i ~ Bile stasis - ~ _ ~ infection, , ~ I 1" =_1 ~ - ~ ~[ scarring ano

~ ] [ (][ ~]Stone formation~f~. ~ thickening of

~ 1 ~ ,,~ ~ ~ ~ ~ . .-J d i s t a l I ~ ~ ' -z~'ld ~ ~ ) Y " ~ - . ~ j ~ duct wall

~-~O~ segment k ~ ; ~'~" ~ + " ~ . Inflammatory

Choledochal cyst Congenital hypotonia Choledochitis

Fig. 4. Three types of nonobstructive dilatation of common bile duct~

stomy in order to prevent bile stasis and recurrence of gallstones in the congenia- tally dilated bile ducts, and they stated that most bilirubin stones present in the duct are probably formed primarily in the duct due to bile stasis) Longmire and Magiola depicted three types of nonobstructive dilatation of the com- mon duct: 1) congenital cystic dilatation

showed increasing dilatation with aging. Thus dilatation of the common duct is one of the physiological phenomena of aging, perhaps due to loss of elasticity of the wall of this organ.

A collective review of patients with congenital choledochal cysts up to 1966, (the period of survey limited to 1966 because thereafter there was a confusion in

of the common hypotonia of the common duct, and 3) inflammatory choledochitis 2 (Fig. 4).

We reported findings in 27 patients who underwent reoperation for recurrent, not residual, common duct stones and recommended bilioenterostomy for patients with bilirubin stones in an extensively dilated common duct, despite apparent patency of the terminal portion. 6 Our present study demonstrated that the common ducts were dilated not only in patients with bilirubin stones but also in

duct, 2) congenital Japan regarding the definition of con- genital choledochal cysts and congenital dilatation of the common bile duct), revealed fewer patients with bilirubin stones than reported by Matsumoto et al. According to Flanigan's review, among 995 cases of biliary cysts only 19 cases (1.9%) had gallstonesA All these data taken together showed that the dilatation of common duct might not be of congenital origin and might not be related to bilirubin stone formation.

On the basis of our present knowledge those with cholesterol stones. This of bililiary physiology and biochemistry, observation indicated that common duct we should reserve any drainage operations dilatation in a considerable number of such as choledochoenterostomy for care- cholelithic patients is the result of re- fully screened patients, since these opera- sidence or passage of gallstones. The tions inevitably induce a non-physiologic common duct of patients both having condition which is naturally burdened gallstones in the gallbladder alone and with risks of provoking postoperative of the persons with normal biliary tracts complications such as ascending cholangi-

Volume 10 Number 4 Dilatation o f the common bile duct 301

tis. The most suitable candidates for dra inage operations are those who have " recur ren t" stones in the diffusely dilated common bile duct, and t ransduodena l sphincteroplasty is indicated in the presence of stricture of the duodena l papilla, otherwise supraduodenal choledo- choenterostorny is indicated. O n the other hand, congenital choledochal cysts

should be resected as far as possible in order to prevent the risk of cancer

developing in the cyst wall after cysto- enterostomy. Differentiat ion between "re- cur ren t" and "residual or re ta ined" stones should be made not only from characteri- stics of the stones bu t also from the medical history of the patients, par t icu- larly the records of previous surgeries.

References

1. Flanigan, D.P.: Biliary cysts. Ann Surg 182: 635, 1975.

2. Longmire, W.P., Magiola, S.: Nonobstructive dilatation of the common duct. Surg Clin N Amer. 50: 1099, 1970.

3. Madden, J.L., Vanderheyden, L., Kandalaft, S.: The nature and surgical significance of common duct stones. SGO 126: 3, 1968.

4. Maki, T.: Pathogenesis of calcium bilirubinate gallstone: role of E. coli, fl-glucuronidase and coagulation by inorganic ions, polyeleetrolytes and agitation. Ann. Surg, 164: 90, 1966.

5. Matsumoto, Y., Uchida, K., Nakase et al.: Con- genital cystic dilatation of the common bile duct as a cause of primary duct stones. Amer. J. Surg., 134: 346, 1977.

6. Nagase, M., Setoyama, Hikasa, Y.: Recurrent common duct stones, with special reference to primary common duct stones. Gastroenterologica Japonica. 13: 290, 1978.

(Received for publ ica t ion on Aug. 20, 1979)