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Chapter 24 / Sphincter of Oddi Dysfunction 311
Suggested Readings
Behar J, Corazziari E, Guelrud M, et al. Functional gallbladder and sphincter of Oddi
disorders. Gastroenterology 2006;130:1498–1509.
Cheng CL, Sherman S, Watkins JL, et al. Risk factors for post-ERCP pancreatitis:
a prospective multicenter study. Am J Gastroenterol 2006;101:139–147.
Eversman D, Fogel EL, Rusche M, et al. Frequency of abnormal pancreatic and biliary
sphincter manometry compared with clinical suspicion of sphincter of Oddi dys-
function. Gastrointest Endosc 1999;50:637–641.
Freeman ML, Guda NM. Prevention of post-ERCP pancreatitis: a comprehensive
review. Gastrointest Endosc 2004;59:845–864.
Freeman ML, Gill M, Overby C, et al. Predictors of outcomes after biliary and pan-
creatic sphincterotomy for sphincter of Oddi dysfunction. J Clin Gastroenterol
2007;41:94–102.
Madura JA II, Madura JA. Diagnosis and management of sphincter of Oddi dysfunc-
tion and pancreas divisum. Surg Clin North Am 2007;87:1417–1429.
Morgan KA, Romagnuolo J, Adams DB. Transduodenal sphincteroplasty in the man-
agement of sphincter of Oddi dysfunction and pancreas divisum in the modern
era. J Am Coll Surg 2008;206(5):908–914; discussion 914–917.
Park SH, Watkins JL, Fogel EL, et al. Long-term outcome of endoscopic dual pan-
creatobiliary sphincterotomy in patients with manometry-documented sphinc-
ter of Oddi dysfunction and normal pancreatogram. Gastrointest Endosc
2003;57:483–491.
Sgouros SN, Pereira SP. Systematic review: sphincter of Oddi dysfunction—non-
invasive diagnostic methods and long-term outcome after endoscopic sphincter-
otomy. Aliment Pharmacol er 2006;24:237–246.
Venu RP, Geenen JE, Hogan WJ. Sphincter of Oddi stenosis and dysfunction. In: Sivak
MV Jr, ed. Gastroenterologic endoscopy, 2nd ed. Philadelphia, PA: WB Saunders,
2000:1023.
Dr. Fogel has provided an outstanding overview of sphincter of Oddi dys-
function, pathophysiology, and treatment. is editorial side bar is focused
on the technique of surgical transduodenal sphincteroplasty.
1. e patient is approached through upper midline or right subcostal inci-
sion. A wide Kocher maneuver is essential to mobilize the duodenum
into the operative eld. Stay sutures placed on the duodenum are useful;
stay sutures placed adjacent to the papilla are helpful as well in elevating
the head of the pancreas and duodenum into the operative eld; however,
care must be taken to avoid occluding the biliary or pancreatic sphincter.
e duodenum is opened longitudinally over the major papilla, which is
easily identiable by palpation or ultrasound. In dicult cases, a probe
may be passed antegrade through the cystic duct and distal common bile
duct to identify the papillary orice.
2. Once the papilla is exposed (see gures), the bile duct and pancre-
atic duct are intubated with small (5 French) pediatric feeding tubes.
Sphincteroplasty of the biliary sphincter is performed rst. e tissue
may be divided sharply between ne-tipped clamps prior to suturing.
Alternatively, the sphincterotomy may simply be created/extended care-
fully using a needle tip cautery. If the latter approach is used, my prefer-
ence is to cauterize over the plastic feeding tube (not over a metal probe)
to minimize chance for inadvertent tissue injury. Care must be paid at
this point of the operation to avoid extending the sphincterotomy too far
(both in the biliary and pancreatic sphincter)—perforation into the ret-
roperitoneum is associated with potentially disastrous consequence. e
sphincteroplasty is completed by suturing the biliary epithelium to the
duodenal epithelium with long-acting absorbable sutures or nonabsorb-
able monolament sutures. e pancreatic sphincteroplasty (septotomy)
Section III / Biliary312
is created between the biliary and pancreatic ductal orice (see gures).
Again, care is taken here not to extend the septotomy too deeply. It is
prudent to leave a short segment (4 to 5 cm) of pediatric feeding tube in
the pancreatic duct to minimize chances of postoperative pancreatitis.
is tube is secured with chromic suture to ensure short-term stability
Operative (A) and schematic (B) illustration of sphincteroplasty with septoplasty.
Chapter 24 / Sphincter of Oddi Dysfunction 313
but promote early passage. Should the patient have pancreas divisum,
the minor papilla is addressed in a similar fashion.
3. e duodenotomy is closed transversely in two layers. Routine drainage
is not necessary; however, may be considered if concern for retroperito-
neal incursion is high.
4. Patients are typically counseled preoperatively to expect full liquid diet
or soft mechanical diet for the rst few postoperative weeks. Immediate
postoperative laboratory evaluation includes liver chemistry and serum
amylase or lipase. Diet advancement is delayed if the patient manifests
biochemical pancreatitis. If patients have early postoperative epigastric
or right upper quadrant pain, abdominal x-ray should be obtained to
ensure passage of pancreatic stent.
314
ETIOLOGY
Common bile duct (CBD) stones can be classied as either primary or
se
condary. Primary CBD stones develop de novo within the bile ducts,
whereas secondary stones develop in the gallbl adder and subsequently pass
into the CBD. In the United States, more than 85% of all bile duct stones are
secondary. Primary duct stones typically occur in conditions associated
with biliary stasis such as benign biliary strictures, sclerosing cholangitis,
choledochal cyst disease, oriental cholangiohepatitis, or sphincter of Oddi
dysfunction. Bile stasis promotes the overgrowth of bacteria in bile with
subsequent bilirubin deconjugation and the breakdown of biliary lipids,
resulting in the formation of brown pigment stones. Secondary bile duct
stones have a composition similar to gallbladd er stones: approximately 75%
are cholesterol stones, and 25% are black pigment stones. e classica-
tion of CBD stones into primary or secondary is of therapeutic importance
because primary stones require removal of the stones and a drainage pro-
cedure (choledochoenterostomy or sphincteroplasty), whereas secondary
stones can be treated by removal of the stones and cholecystectomy.
Most patients with CBD stones are asymptomatic. It is estimated
that CBD stones (choledocholithiasis) are found in approximately 10%
of patients with cholelithiasis. is incidence of CBD stones in patients
undergoing cholecystectomy ranges between 8% and 15%. e incidence
varies with age and is less than 5% in younger patients and more than 20%
in older patients with gallstones. Patients with symptomatic CBD stones
may present with biliary colic, extrahepatic biliary obstruction, cholangi-
tis, or pancreatitis. Typically, the pain and jaundice associated with CBD
stones are more intermittent and transient than when the biliary obstruc-
tion is caused by a malignancy. Fever and chills are present in patients with
cholangitis. Gallstone pancreatitis can develop from the obstruction of
the ampulla of Vater by common duct stones. In the west, CBD stones are
responsible for up to 50% of all cases of pancreatitis. Most patients with
gallstone pancreatitis experience a mild self-limited attack from which they
recover within a few days; however, some patients will progress to develop
severe pancreatitis with peripancreatic necrosis, infection, or other local
complications.
DIAGNOSIS
No single clinical variable is completely accurate in predicting the pres-
ence of choledocholithiasis. erefore, the results of a detailed history and
physical examination, laboratory evaluations, and diagnostic imaging tests
must be considered together when assessing the likelihood that a patient
has CBD stones. Serum liver function tests (bilirubin, alkaline phospha-
tase, and transaminases) can be useful in predicting common duct stones.
Common Bile Duct Stones
and Exploration
Attila Nakeeb
25
Chapter 25 / Common Bile Duct Stones and Exploration 315
In the setting of suspected CBD stones, if any one value of the liver prole is
elevated, the risk for CBD stones approaches 20%. With two elevated values,
the risk increases to nearly 40%, and with three or more elevated values,
the risk for CBD stones is nearly 50%. Factors associated with a high risk of
choledocholithiasis include cholangitis, CBD size greater than 6 mm, CBD
stones visualized on ultrasound (US) or cross-sectional imaging, and jaun-
dice (bilirubin >4 mg/dL).
DIAGNOSTIC STUDIES
Transabdominal Ultrasonography
US is highly sensitive for the diagnosis of gallstones within the gallbladder.
Unfortunately, the sensitivity of transabdominal US for the detection of
CBD stones is only 30% to 50%. US successfully identies the presence of
CBD stones in only 70% of patients because the distal bile duct is frequently
obscured by duodenal or colonic gas. On the other hand, transabdominal
US is very sensitive for identifying CBD dilation, which can suggest choledo-
cholithiasis. If the extrahepatic bile duct diameter is less than 3 mm, CBD
stones are exceedingly rare, whereas a CBD diameter greater than 10mm in
a jaundiced patient is associated with CBD stones in more than 90% of cases.
Magnetic Resonance Imaging
Magnetic resonance cholangiopancreatography (MRCP) has a sensitivity of
90%, a specicity of 100%, and an overall diagnostic accuracy of 97% for the
diagnosis of CBD stones. MRCP (Fig. 25.1) permits direct imaging of the bili-
ary tract without the need for contrast, radiation exposure, or an invasive
FIGURE 25.1 MRCP demonstrating CBD stones.
Section III / Biliary316
procedure. Disadvantages of MRCP include its relatively high cost, the need
for prolonged breath holding, and a lack of therapeutic options. MRCP can
be used to screen patients at low and moderate risk of having common duct
stones prior to endoscopic cholangiography. A normal magnetic resonance
cholangiogram can eliminate the need for an invasive endoscopic cholan-
giogram or intraoperative cholangiogram.
Endoscopic Ultrasound
Endoscopic ultrasound (EUS) is a semi-invasive test that can be performed
with a very low rate of complications (<0.1%). e sensitivity (92% to 100%)
and specicity (95% to 100%) for the diagnosis of CBD stones by EUS are
excellent. e negative predictive value for EUS is more than 97%. erefore,
when EUS is negative for common duct stones, endoscopic retrograde chol-
angiopancreatography (ERCP) or intraoperative cholangiography (IOC)
can be avoided.
Direct Cholangiography
Direct cholangiography is the gold standard for diagnosing CBD stones.
Both endoscopic retrograde cholangiography (ERC) and percutaneous
transhepatic cholangiography (PTC) techniques can be used to directly
visualize the biliary tree. In addition to identifying CBD stones, endoscopic
cholangiography (Fig. 25.2) permits safe removal of most stones and is there-
fore the preferred approach for patients with suspected CBD stones. Skilled
endoscopists can successfully cannulate the CBD in 90% to 95% of patients.
Complications of diagnostic cholangiography including pancreatitis and
cholangitis occur in approximately 5% of patients; the vast majority of
these complications are mild and self-limiting. ERC may be unsuccessful in
patients with previous gastric surgery (Billroth II
reconstruction, Roux-en-Y
FIGURE 25.2 ERCP demonstrating CBD stones.
Chapter 25 / Common Bile Duct Stones and Exploration 317
gastric bypass), periampullary diverticula, or tortuous bile ducts. PTC may
be used to image the bile ducts if ERC is unsuccessful.
Intraoperative Cholangiography
IOC also can be successfully accomplished in more than 95% of cases. e
cholangiogram should be carefully evaluated for lling defects within the
ducts, presence of contrast in the duodenum, and the intrahepatic bili-
ary anatomy (Fig. 25.3). Importantly, the surgeon must be able to interpret
IOC images in real time, in the operating room for this study to be valu-
able. Debate continues over the need to perform routine IOC at the time
of cholecystectomy. Advocates of routine IOC argue that asymptomatic
CBD stones can be identied and biliary injuries prevented by performing
routine IOC. Critics of this approach suggest that the incidence of retained
stones is no greater when cholangiography is performed selectively based
on clinical and laboratory criteria. e indications for performing cholangi-
ography during cholecystectomy include (a) a dilated CBD, (b) a wide cystic
duct, (c) palpable CBD stones, (d) elevated serum liver function tests or bili-
rubin, and (e) a history of pancreatitis. If these criteria are strictly followed,
approximately 30% of patients will require IOC at the time of cholecystec-
tomy. In addition to dening biliary anatomy, IOC can identify the size,
number, and location of CBD stones. is information is critical in choosing
the most appropriate treatment for CBD stones.
Intraoperative Ultrasonography
Intraoperative ultrasonography also can be used to identify CBD stones at the
time of cholecystectomy. In experienced hands, intraoperative ultrasonogra-
phy has been shown to be comparable to IOC for the diagnosis of CBD stones.
Laparoscopic ultrasonography is performed with a high-frequency (7.5- to
10-mHz) probe, and the bile duct is imaged in the transverse and longitudinal
planes. e distal bile duct can be visualized in more than 95% of cases.
Left hepatic
duct
Dilated common
bile duct
Meniscus of stone
blocking CBD
Cystic duct
Right hepatic
duct
FIGURE 25.3 Intraoperative cholangiogram. (From
Lillemoe K, Jarnigan W. Master techniques in surgery:
hepatobiliary and pancreatic surgery. Philadelphia, PA:
Lippincott Williams & Wilkins, 2012.)
Section III / Biliary318
General Diagnostic Strategy
e choice of radiologic studies used to evaluate a patient with suspected
choledocholithiasis should be based on the probability of this diagnosis.
Asimple algorithm for the workup of patients with CBD stones is shown in
Figure 25.4. Patients at highest risk for choledocholithiasis should undergo
endoscopic cholangiography. Patients at intermediate risk may be screened
with magnetic resonance cholangiography or EUS and proceed to laparo-
scopic cholecystectomy if no stones are identied. ose patients at low
risk of harboring common duct stones may be evaluated with IOC at the
time of laparoscopic cholecystectomy with laparoscopic CBD exploration
or postoperative endoscopic stone extraction reserved for the few patients
with a positive study.
MANAGEMENT
Currently, several options are available to the surgeon for the treatment of
CBD stones. In choosing the most appropriate approach for an individual
patient, factors such as the local endoscopic expertise, the surgeon’s laparo-
scopic skill, and the patient’s clinical condition must be considered.
ENDOSCOPIC THERAPY
ERC with endoscopic sphincterotomy permits CBD stones to be removed
without the need for conventional surgery. Stones can be successfully
removed from the CBD in 85% to 95% of cases. e endoscopic approach
is particularly useful for patients prior to cholecystectomy in whom a high
suspicion exists for CBD calculi, particularly if laparoscopic CBD explora-
tion is not available. Endoscopic clearance of stones from the CBD precho-
lecystectomy can obviate the need for an open operation. Furthermore, if
Symptomatic cholelithiasis +/− choledocholithiasis
Debilitated
Elderly
ERC / ES
ERC / ES
ERC / ES
Postoperative
ERC / ES
Stones
Stones
CBDE / t-tube
Transcystic
Extraction
Stones
Stones
Removal Via T-tube
Stones
No Stones
Open CBDE
T-tube
Drainage
Procedure
Contraindications
to Laparoscopy
Open
Cholecystectomy
Intraoperative
Cholangiogram
or Ultrasound
Jaundice
Dilated CBD
Severe Pancreatitis
Cholangitis
Elevated LFTs
Laparoscopic
Cholecystectomy
Remove
T-tube
Follow
Retained
Stones
FIGURE 25.4 Algorithm for the management of CBD stones. (From Mulholland MW,
Lillemoe KD, Doherty GM, et al. Greeneld’s surgery: scientic principles & practice, 5th
ed. Philadelphia, PA: Lippincott Williams & Wilkins, 2010.)
Chapter 25 / Common Bile Duct Stones and Exploration 319
endoscopic stone extraction is not possible because of multiple gallstones,
intrahepatic stones, large gallstones, impacted stones, duodenal diver-
ticula, prior gastrectomy, or bile duct stricture, this information is known
preoperatively, and an open CBD exploration or drainage procedure can
be performed at the time of cholecystectomy. After sphincterotomy, most
stones smaller than 1 cm in diameter pass spontaneously. A balloon cath-
eter or stone basket also can be used to retrieve stones if needed. If endo-
scopic clearance is incomplete, an endoscopic stent can be placed into the
CBD to maintain drainage and prevent cholangitis.
Endoscopic sphincterotomy and stone extraction is well tolerated in
most patients. Complications occur in 5% to 8% of patients and include
cholangitis, pancreatitis, perforation, and bleeding. e overall mortal-
ity rate is 0.2% to 0.5%. Complete clearance of all common duct stones is
achieved endoscopically in 71% to 75% of patients at the rst procedure and
in 84% to 95% of patients after multiple endoscopic procedures.
Preoperative ERC plus endoscopic sphincterotomy is the preferred
management option for CBD stones in several conditions. In the setting
of acute suppurative cholangitis, morbidity and mortality are signicantly
decreased if preoperative biliary decompression and stone removal are
accomplished before cholecystectomy. Patients with severe gallstone pan-
creatitis or a signicant deterioration of their clinical condition also have
been shown to benet from early ERC and stone clearance. Cholecystectomy
can then be performed after the pancreatitis has resolved. In patients with a
dilated CBD (>8 mm) on US and jaundice, an ERC also should be performed
to rule out a malignancy or biliary stricture that would alter the surgical
management. In patients with a high operative risk, ERC plus endoscopic
sphincterotomy can be performed or denitive treatment to remove CBD
stones and the gallbladder left in place.
LAPAROSCOPIC THERAPY
Laparoscopic exploration of the CBD for choledocholithiasis enables
appropriately selected patients to undergo complete management of
their calculus biliary tract disease with one procedure. e laparoscopic
approach is ideal for patients with CBD stones identied during IOC or US.
e two approaches for laparoscopic bile duct exploration are laparoscopic
transcystic duct bile duct exploration (LTCBDE) or laparoscopic choledo-
chotomy (Table 25.1). e indications for transcystic duct exploration are
Transcystic Choledochotomy
Stones
Number <8 Any
Size <9 mm Any
Location Distal to cystic duct Entire duct
Bile duct size Any >6 mm
Drain Optional cystic duct tube T-tube
Contraindications
Advantages
Friable cystic duct
Intrahepatic stones
Multiple large stones
Small diameter duct
Inability to suture
laparoscopically
T-tube for postoperative
access No T-tube
Short hospital stay
Laparoscopic Transcystic CBD Exploration versus
Laparoscopic Choledochotomy
TABLE
25.1
Section III / Biliary320
lling defects noted on cholangiography (CBD stones), stones less than 9
mm in diameter, stones distal to the cystic duct entrance to the bile duct,
and less than six stones. Contraindications to LTCBDE are a small friable
cystic duct, more than eight stones in the CBD, common hepatic duct
stones, and stones larger than 1 cm. Laparoscopic choledochotomy can
be performed if LTCBDE fails or is contraindicated, if stones are present
proximal to the cystic duct, or when multiple stones are present. e only
contraindication to laparoscopic choledochotomy is a small common duct
(<6 mm) that might be narrowed during its closure.
Laparoscopic Transcystic Duct Bile Duct Exploration
e technique of LTCBDE involves careful dissection of the cystic duct
down to its junction with the CBD. A clip is placed on the gallbladder side
of the cystic duct and a ductotomy is created sharply. After completing a
cholangiogram, a guide wire should be inserted into the bile duct. A chol-
angiocatheter can then be advanced over the guide wire into the bile duct
and saline irrigated through the catheter in an attempt to ush small stones
out of the bile duct. Glucagon should be administered intravenously to
encourage relaxation of the sphincter of Oddi. If the stones in the CBD are
larger than the lumen of the cystic duct, the cystic duct can be dilated with
a series of dilators using either the Seldinger technique or an angioplasty
balloon catheter. Stone retrieval baskets can be inserted over the guide wire
and stones extracted under uoroscopic guidance. Flexible choledochos-
copy via the cystic duct also can be performed and stones extracted under
direct vision using baskets (Fig. 25.5). Success rates greater than 95% have
been reported for bile duct clearance using choledochoscopy. To document
FIGURE 25.5 Laparoscopic transcystic duct CBD exploration. (From Lillemoe K,
Jarnigan W. Master techniques in surgery: hepatobiliary and pancreatic
surgery. Philadelphia, PA: Lippincott Williams & Wilkins, 2012.)