Do surgical and endoscopic sphincterotomy prevent or facilitate recurrent common duct stone formation?
F. Cetta
Interuniversity Center for Research in Hepatobiliary Diseases, University of Siena, Italy.
The possible formation of brown recurrent common duct stones (RCS) as a
long-term side effect of sphincterotomy (SPHT) has been evaluated in 63
patients with stone formation after cholecystectomy, 253 who underwent SPHT
or choledocholithotomy, 131 with postoperative monitoring of bile
bacteriologic characteristics through the T tube, and 20 with stone and
bile analysis at both operations. In addition, findings are also reported
in 145 patients who underwent surgical SPHT and radiologic review of up to
28 years after surgery, five who underwent ampullectomy, and 55 who
underwent endoscopic SPHT. The RCS were usually brown (72.5% of cases), and
were always associated with bile infection caused by Escherichia coli.
Sixty-two percent of brown RCS were found after SPHT. Eleven percent of
patients who underwent surgical SPHT, 9% who underwent endoscopic SPHT, and
66.6% who underwent ampullectomies had brown RCS. Sphincterotomy determined
a fivefold greater incidence of postoperative bactibilia, and a seven-fold
greater incidence of brown RCS, than did choledocholithotomy. It is
suggested that: (1) since brown RCS are secondary to bile contamination
from the duodenum, SPHT (and subsequent stricture), facilitating both bile
contamination and bacterial overgrowth, could be considered a basic factor
in the formation of these stones; and (2) since true RCS are mostly of the
brown subtype, SPHT could prevent the occurrence of retained stones by
flushing the stones that were missed during the first operation, but
undoubtedly increases the total incidence of RCS.
