Rare recurrence of common bile duct calculi post T-tube cholangiography: A case report

Abstract

BACKGROUND

Recurrence of common bile duct (CBD) calculi within 30 days following T-tube cholangiography is exceedingly rare.

CASE SUMMARY

This article details an instance of choledocholithiasis involving a 1.2 cm × 0.9 cm stone located in the lower and middle segments of the CBD, identified 30 days after T-tube cholangiography, accompanied by multiple microstones. Magnetic resonance cholangiopancreatography revealed dilation of both intrahepatic and extrahepatic bile ducts, with the widest segment of the CBD measuring approximately 2 cm. The patient underwent laparoscopic choledochal exploration followed by choledochojejunostomy using the Roux-en-Y technique.

CONCLUSION

Although recurrence of choledocholithiasis within such a short postoperative period is exceedingly uncommon, this case underscores the necessity for clinicians to remain vigilant regarding the potential for early postoperative recurrence.

Key Words: Choledocholithiasis; Early recurrence; Common bile duct stones; T-tube cholangiography; Case report

Core Tip: Thirty days subsequent to undergoing T-tube cholangiography following common bile duct (CBD) exploration and cholecystectomy, a patient was diagnosed with recurrent CBD stones by magnetic resonance cholangiopancreatography. Despite the rarity of CBD stone recurrence within such a brief postoperative interval, this case underscores the imperative for clinicians to remain highly vigilant concerning the potential for early postoperative recurrence.

INTRODUCTION

Gallstone disease frequently requires surgical treatment, with about 35% of patients experiencing symptoms that lead to a cholecystectomy[1]. Among the cholecystectomies performed annually for cholelithiasis, the incidence of common bile duct (CBD) stones ranges from 5% to 15%[2]. Obstructive stones in the CBD can originate from the CBD, the gallbladder, or ducts either outside or inside the liver. Magnetic resonance cholangiopancreatography (MRCP) demonstrates high diagnostic accuracy for the detection of choledocholithiasis[3]. The presence of CBD stones poses significant concerns due to the potential development of complications such as obstructive jaundice, biliary pancreatitis or acute cholangitis if left untreated, which can result in adverse morbidity or even mortality[4]. The recurrence rate of CBD stones following stone extraction is reported to be between 4% and 24%[5]. The mean time to recurrence of CBD stones is 19.7 months, with a range of 5-72 months[6]. Currently, the optimal treatment for choledocholithiasis remains a subject of debate. The two most widely accepted techniques are endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy (LC) and laparoscopic CBD exploration (LCBDE)[7].

CASE PRESENTATION

Chief complaints

A 72-year-old man was readmitted to the Department of Geriatric Surgery at the First Affiliated Hospital of Xi’an Jiaotong University, China, because of recurrent choledocholithiasis, occurring 5 days after choledocholithotomy performed 2 months prior.

History of present illness

Two months prior, the patient had undergone laparoscopic choledochotomy combined with LC for treatment of gallbladder stones and choledocholithiasis.

History of past illness

He had a 15-year history of hypertension, with recorded maximum blood pressure levels reaching 29.3/13.3 kPa, and had previously undergone appendectomy at a local hospital.

Personal and family history

There is no record of related diseases in the family, and no history of infectious and genetic diseases.

Physical examination

Clinical examination revealed pressure-induced pain in the right upper abdomen.

Laboratory examinations

Routine hematological and biochemical investigations, including hemoglobin levels, total white blood cell count, and liver function tests, indicated serum total bilirubin concentration of 31.4 mg/dL, aspartate aminotransferase level of 19 U/L and alanine aminotransferase level of 16 U/L. Renal function tests, serum electrolytes, serum glucose, and urinalysis results were within normal limits (Table 1).

Table 1 Renal function tests, serum electrolytes, serum glucose, and urinalysis results were within normal limits.

Date	At admission	At discharge	Lab reference values
Hemoglobin	136	133	130-175 g/L
WBC	7.34	13.45	3.5-9.5 × 1012/L
Platelets	215	224	125-350 × 109/L
PT/INR	13.1/1.02	-	11-14/0.94-1.30
TBIL	31.4	56.5	3.4-17.1 μmol/L
DBIL	10.6	19.1	0-3.4 μmol/L
IBIL	20.8	37.4	0-17.1 μmol/L
ALT	16	20	9-50 U/L
AST	19	16	15-40 U/L
ALP	170	140	45-125 U/L
GGT	153	114	10-60 U/L
Total protein	67.7	67.2	65-85 g/L
Albumin	34.2	36.6	40.0-55.0 g/L
Globulin	33.5	30.6	20.0-40.0 g/L
Urea/creatinine	57/3.39	55/3.49	57-111/3.60-9.50
Sodium/potassium	141.4/4.17	136.9/2.88	135-145/3.5-5.5
anti-HIV/anti-HbsAg/anti-HCV	Non-reactive	-	-

WBC: White blood cell; PT: Prothrombin time; INR: International normalized ratio; TBIL: Total bilirubin; DBIL: Direct-bilirubin; IBIL: Indirect bilirubin; ALT: Alanine aminotransferase; AST: Aspartate aminotransferase; ALP: Alkaline phosphatase; GGT: Gamma-glutamyl transferase; HIV: Human immunodeficiency virus; HbsAg: Hepatitis B surface antigen; HCV: Hepatitis C virus.

Imaging examinations

T-tube cholangiography conducted 30 days postoperatively indicated that the bile ducts were patent with no evidence of filling defects (Figure 1), leading to subsequent removal of the T-tube. Preoperative MRCP for initial LCBDE + LC revealed a mildly dilated CBD, right and left hepatic ducts, common hepatic duct, and intrahepatic bile ducts. The CBD exhibited nodular filling defects measuring 0.6-0.7 cm in diameter and demonstrated hypodensity on T2-weighted imaging (Figure 2A and B). High-density calculi were also observed within the dilated CBD. Preoperative MRCP for subsequent LCBDE did not visualize the gallbladder. The maximum diameter of the CBD measured approximately 2.0 cm, with multiple rounded low-signal shadows identified in the middle and lower segments of the duct, the largest of which measured approximately 1.2 cm × 0.9 cm (Figure 2C and D).

Figure 1 T-tube imaging image 30 days after the first laparoscopic common bile duct exploration with laparoscopic cholecystectomy procedure.

Figure 2 T2 coronal image shows bi-lobar central and peripheral intrahepatic biliary tract dilatation and dilated common bile duct with distal smooth tapering of common bile duct. White solid arrow: The filling defect.

FINAL DIAGNOSIS

Recurrent choledocholithiasis.

TREATMENT

The patient signed informed consent for surgery and was scheduled for elective surgery. Intraoperatively, extensive adhesions were observed in the epigastric region. The gallbladder was absent, and significant dilation of the extrahepatic bile ducts was noted. The middle portion of the CBD measured approximately 1.2 cm in diameter and exhibited normal alignment. No anomalies were detected in the stomach, spleen, small intestine, colon or mesentery. Subsequently, meticulous dissection of the hepatic hilum was performed. The anterior and superior segments of the CBDs were liberated utilizing suction, followed by incision with electrocautery. A choledochoscope was introduced to investigate the thickening of the choledochal wall and mucosal roughness, revealing multiple stones within the CBD. These stones were individually extracted using a stone extraction basket, and any residual fragments were flushed out with saline. The CBD was transected using an ultrasonic knife, and the distal end was closed with interrupted sutures using Prolene 4-0 barbed wire. The proximal end of the CBD was mobilized and prepared for choledochojejunal anastomosis. The distal jejunum was elevated approximately 25 cm from the ligament of Treitz, and a longitudinal incision of approximately 1.0 cm was made along the antimesenteric border of the intestinal lumen. The jejunum and the transected end of the choledochal duct were approximated using interrupted sutures with 4-0 barbed wire on both the anterior and posterior walls. Upon completion of the suturing, the anastomosis was assessed for bile leakage, which was found to be minimal, indicating a tension-free closure. Approximately 60 cm distal to the biliary-intestinal anastomosis, a side-to-side anastomosis was performed between the proximal and distal jejunum using a linear cutting closure device along the mesenteric border. The common opening was subsequently closed with 4-0 barbed suture. Post-suturing, the anastomosis was evaluated for patency, absence of tension, and adequate intestinal blood flow, confirming successful completion of the procedure. Additionally, the proximal jejunum was transected using a linear cutting closure device approximately 5 cm from the biliary anastomosis. Following verification of the absence of active bleeding, a drain was positioned at the site of the biliary anastomosis and exteriorized through the abdominal wall. The abdominal closure was performed in a layered manner. Figure 2E-H illustrates intraoperative images documenting extraction of a stone from the bile duct. Serum total cholesterol levels exhibited a progressive decline. Prior to the initial surgical intervention, the total cholesterol level was 2.3 mmol/L. Following initial surgery, it decreased to 2.13 mmol/L, and after the second operation, it further declined to 2.07 mmol/L. This ongoing reduction in cholesterol levels suggested that the CBD stones were primarily composed of cholesterol. The formation of cholesterol stones is closely associated with cholesterol supersaturation in bile, and the gradual decrease in cholesterol levels postoperatively may reflect improvement in bile composition and a reduction in stone burden. This alteration not only corroborates the diagnosis of cholesterol stones but also serves as a significant biochemical index for postoperative monitoring. These surgical images confirm the presence of multiple stones, consistent with the obstruction observed in the MRCP scan.

OUTCOME AND FOLLOW-UP

Following the surgical procedure, the patient initially demonstrated satisfactory recovery. However, 2 months postoperatively, the patient presented with symptoms indicative of bile duct inflammation; notably, recurrence of right upper abdominal pain. MRCP examination revealed no significant presence of calculi (Figure 3). The patient underwent symptomatic management, which included administration of anti-infective agents, anti-inflammatory cholagogue, and laxatives aimed at alleviating intestinal pressure. This therapeutic approach resulted in the patient's recovery, leading to discharge from hospital. The patient expressed satisfaction with the treatment received.

Figure 3 Magnetic resonance cholangiopancreatography did not reveal any significant calculi.

DISCUSSION

Data indicate that the prevalence of CBD stones in patients presenting with symptomatic gallstones is between 10% and 20%[8,9]. Recurrence of bile duct stones has been reported in 3.7%-24% of patients, even following the complete removal of the stones[6,10-13]. ERCP is usually the main treatment for CBD stones. However, different techniques including percutaneous and transhepatic stone removal, open CBD exploration, and laparoscopic approaches are also applied. Notably, LCBDE offers advantages in terms of fewer complications and reduced treatment costs compared to ERCP, suggesting its potential for broader clinical application[14]. In a study involving 458 patients with an average long-term follow-up of 6.8 years after choledocholithiasis surgery, approximately 3.9% experienced recurrence within the first 2 years, with most recurrences occurring beyond this period. The minimum duration for recurrence of choledocholithiasis postoperatively has yet to be documented. The incidence of recurrent choledocholithiasis within 30 days following T-tube angiography is exceedingly rare[15]. MRCP serves as a noninvasive modality capable of detecting choledocholithiasis in the preoperative setting[3]. Factors such as age, choledochal diameter, genetic predisposition, and other variables may contribute to the recurrence of choledochal stones[16]. Postoperative strategies to mitigate the risk of CBD stone recurrence include adherence to a healthy diet, regular exercise, and administration of ursodeoxycholic acid[17].

CONCLUSION

This case report presents an instance of recurrent choledocholithiasis occurring within 30 days following T-tube cholangiography, characterized by a stone measuring 1.2 cm × 0.9 cm situated in the lower and middle segments of the choledochotomy, accompanied by multiple microstones. Although the recurrence of choledocholithiasis within such a short postoperative period is exceedingly uncommon, this case underscores the necessity for clinicians to remain vigilant regarding the potential for early postoperative recurrence. This is particularly pertinent for patients at elevated risk, such as those exhibiting bile duct dilatation (CBD diameter ≥ 2 cm) or the presence of microscopic stone remnants.