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Gallbladder

I have stones in the gallbladder and in the bile duct. Is that one operation or two?

The gallbladder and the bile duct are different structures, and a stone that has moved from one to the other adds a second problem that has to be solved as well.

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Answer

Both routes are in routine use — clearing the duct endoscopically first and removing the gallbladder afterwards, or doing both in a single laparoscopic operation — and a meta-analysis of 13 studies covering 1,757 patients found the single-operation route cleared the duct in 94.1 percent of cases against 90.1 percent, with fewer perioperative complications, fewer retained stones and a shorter stay, while deaths did not differ.

Key takeaways

  • The gallbladder stores bile; the common bile duct carries it to the intestine. A stone that leaves the gallbladder and lodges in the duct can block the drainage of bile and the pancreas, which is why it is treated rather than watched.
  • Bile duct stones are present in 5 to 15 percent of people having their gallbladder removed for gallstones.
  • In a meta-analysis of 13 studies and 1,757 patients, single-stage laparoscopic bile duct exploration with cholecystectomy cleared the duct in 94.1 percent of cases against 90.1 percent for endoscopic sphincterotomy followed by cholecystectomy.
  • In the same analysis, perioperative complications were 7.6 percent against 12.0 percent, retained stones 1.2 percent against 7.9 percent, and recurrence of stones 1.8 percent against 5.6 percent, all favouring the single-stage route.
  • Hospital stay in that analysis was 4.94 days against 6.62 days and operating time 112 minutes against 132 minutes, while mortality was 0.6 percent against 1.1 percent and did not differ significantly.
  • A separate randomised comparison of 120 patients found clearance of 96.5 percent for the single-operation route and 94.4 percent for endoscopic clearance followed by surgery.
  • Which route a hospital offers depends on whether its surgeons perform laparoscopic bile duct exploration, which is a less widely held skill than endoscopic stone removal.

These are two different places, and the distinction is the whole of the question. The gallbladder is a storage sac hanging off the side of the biliary tree. The common bile duct is the pipe that carries bile from the liver to the intestine. A stone forms in the gallbladder; if it escapes down the cystic duct and lodges in the common bile duct, it is in the drainage route for both the liver and the pancreas.

That is why a duct stone is treated and a gallbladder stone without symptoms often is not. It is also why having both means two problems, which can be solved in one sitting or two.

How common it is

Among the cholecystectomies performed each year for gallstones, bile duct stones are present in 5 to 15 percent of cases. Suspicion before surgery is raised by jaundice, by a dilated duct on ultrasound, and by abnormal liver blood tests, and a meta-analysis of 22 studies ranked those signals: cholangitis, preoperative jaundice and ultrasound evidence of a stone in the duct carried positive likelihood ratios of 10 or above, while a raised alkaline phosphatase, pancreatitis or cholecystitis carried ratios below 3.

One operation or two

The two-stage route is the familiar one: an endoscope is passed to the opening of the bile duct, the opening is cut, the stone is retrieved, and the gallbladder is removed laparoscopically afterwards. The single-stage route opens the duct during the same laparoscopic operation that removes the gallbladder.

Single-stage laparoscopic bile duct exploration with cholecystectomy against preoperative endoscopic sphincterotomy followed by cholecystectomy, meta-analysis of 13 studies and 1,757 patients
OutcomeSingle stageTwo stage
Duct cleared of stones94.1%90.1%
Perioperative complications7.6%12.0%
Conversion to another procedure4.1%7.1%
Stones left behind1.2%7.9%
Stones recurring later1.8%5.6%
Operating time112 minutes132 minutes
Hospital stay4.94 days6.62 days
Death0.6%1.1% (not significant)

Every difference in that table except mortality reached statistical significance, and the review concluded that the single-stage approach should be considered the preferred treatment. A prospective randomised study of 120 patients pointed the same way on clearance, at 96.5 percent against 94.4 percent.

A third variation exists, in which the endoscopic clearance is performed during the operation itself rather than days before it, and that has been tested in randomised form against the preoperative sequence for patients at intermediate risk of having a duct stone.

The question worth asking is therefore whether the hospital performs laparoscopic bile duct exploration, and if not, what the interval between the endoscopic procedure and the operation will be — because the interval is when a stone can move again.

Sources

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