In general, bile duct stones, even small ones, should be removed, even in an asymptomatic patient. A bile duct stone in a patient with cholelithiasis or cholecystitis is usually treated by endoscopic sphincterotomy (eFigure 16–53) and stone extraction followed by laparoscopic cholecystectomy within 72 hours in patients with cholecystitis and within 2 weeks in those without cholecystitis. In select cases, laparoscopic cholecystectomy and ERCP can be performed in a single session. An alternative approach, which is also associated with a shorter duration of hospitalization in patients at intermediate risk for choledocholithiasis, is laparoscopic cholecystectomy and bile duct exploration.
For patients older than 70 years or poor-risk patients with cholelithiasis and choledocholithiasis, cholecystectomy may be deferred after endoscopic sphincterotomy because the risk of subsequent cholecystitis is low (although the risk of subsequent complications is lower when cholecystectomy is performed). ERCP with sphincterotomy, generally within 48 hours, should be performed before cholecystectomy in patients with gallstones and cholangitis, jaundice (serum total bilirubin greater than 4 mg/dL [68.4 mcmol/L]), a dilated bile duct (greater than 6 mm), or stones in the bile duct seen on ultrasonography or CT. (Stones may ultimately recur in up to 12% of patients, particularly in older patients, when the bile duct diameter is 15 mm or greater, or when brown pigment stones are found at the time of the initial sphincterotomy.) For bile duct stones 1 cm or more in diameter, endoscopic sphincterotomy followed by large balloon dilation has been recommended. Endoscopic balloon dilation of the sphincter of Oddi is otherwise reserved for patients with coagulopathy because the risk of bleeding is lower with balloon dilation than with sphincterotomy. Balloon dilation is not associated with a higher rate of pancreatitis than endoscopic sphincterotomy if adequate dilation for more than 1 minute is carried out and it may be associated with a lower rate of stone recurrence. EUS-guided biliary drainage and PTC with drainage are second-line approaches if ERCP fails or is not possible. In patients with biliary pancreatitis that resolves rapidly, the stone usually passes into the intestine, and ERCP prior to cholecystectomy is not necessary if intraoperative cholangiography is planned.
Endoscopic sphincterotomy. (Reproduced, with permission, from American Gastroenterological Association, Bethesda, Maryland.)
Choledocholithiasis discovered at laparoscopic cholecystectomy may be managed via laparoscopic or, if necessary, open bile duct exploration or by postoperative endoscopic sphincterotomy. Operative findings of choledocholithiasis are palpable stones in the bile duct, dilatation or thickening of the wall of the bile duct, or stones in the gallbladder small enough to pass through the cystic duct. Laparoscopic intraoperative cholangiography (or intraoperative ultrasonography) should be done at the time of cholecystectomy in patients with liver enzyme elevations but a bile duct diameter of less than 5 mm; if a ductal stone is found, the duct should be explored. In the post-cholecystectomy patient with choledocholithiasis, endoscopic sphincterotomy with stone extraction is preferable to transabdominal surgery. Lithotripsy (endoscopic or external), peroral cholangioscopy (choledoscopy), or biliary stenting may be a therapeutic consideration for large stones. For the patient with a T tube and bile duct stone, the stone may be extracted via the T tube.
Postoperative antibiotics are not administered routinely after biliary tract surgery. Cultures of the bile are always taken at operation. If biliary tract infection was present preoperatively or is apparent at operation, ampicillin-sulbactam (3 g intravenously every 6 hours) or piperacillin-tazobactam (3.375 or 4.5 g intravenously every 6 hours) or a third-generation cephalosporin (eg, ceftriaxone, 1 g intravenously every 24 hours) is administered postoperatively until the results of sensitivity tests on culture specimens are available. A T-tube cholangiogram should be done before the tube is removed, usually about 3 weeks after surgery. A small amount of bile frequently leaks from the tube site for a few days.
Urgent ERCP with sphincterotomy and stone extraction (within 24–48 hours) is generally indicated for choledocholithiasis complicated by acute cholangitis and is preferred to surgery. Before ERCP, liver function should be evaluated thoroughly. The prothrombin time should be restored to normal by intravenous administration of vitamin K. For mild-to-moderately severe community-acquired acute cholangitis, ciprofloxacin (400 mg intravenously every 12 hours), penetrates well into bile and is effective treatment, with metronidazole (500 mg intravenously every 6–8 hours) for anaerobic coverage. An alternative regimen is ampicillin-sulbactam (3 g intravenously every 6 hours). Regimens for patients with severe or hospital-acquired acute cholangitis, and those potentially infected with an antibiotic-resistant pathogen, include intravenous piperacillin-tazobactam (3.375 or 4 g every 6 hours) or a carbopenem such as meropenem (1 g intravenously every 8 hours). Aminoglycosides (eg, gentamicin 5–7 mg/kg intravenously every 24 hours) may be added in cases of severe sepsis or septic shock but should not be given for more than a few days because the risk of aminoglycoside nephrotoxicity is increased in patients with cholestasis. Regimens that include drugs active against anaerobes are required when a biliary-enteric communication is present.
Emergent decompression of the bile duct (within 12 hours), generally by ERCP, is required for patients who are septic or fail to improve on antibiotics within 12–24 hours. Medical therapy alone is most likely to fail in patients with tachycardia, a serum albumin less than 3 g/dL (30 g/L), marked hyperbilirubinemia, a high serum ALT level, a high white blood cell count, and a prothrombin time greater than 14 seconds on admission. If sphincterotomy cannot be performed, the bile duct can be decompressed by a biliary stent or nasobiliary catheter. Once decompression is achieved, antibiotics are generally continued for at least another 3 days. Elective cholecystectomy can be undertaken after resolution of cholangitis, unless the patient remains unfit for surgery. Mortality from acute cholangitis has been reported to correlate with a high total bilirubin level, prolonged partial thromboplastin time, presence of a liver abscess, and unsuccessful ERCP.