cbd gallbladder sizeDecember 15, 2021
With the development of high resolution scanners, the luminal diameters of the common bile duct can be assessed accurately. The normal internal diameter of the common bile duct on ultrasonography is 6 mm . Different opinions regarding the size of the common bile duct have been revealed in literature.
The mean diameters of the common bile duct in the three locations were: proximal, 4.0 mm (SD 1.02 mm); middle, 4.1 mm (SD 1.01 mm); and distal, 4.2 mm (SD 1.01 mm). The overall mean for all measures was 4.1 mm, with a standard deviation of 1.01 mm. All the three diameters were highly correlated and statistically significant (p-value<0.001). While the lower limit of common bile duct diameter among the normal subjects was 2.0 mm, the upper limit was found to be 7.9 mm. However, 95% of the study participants showed a common bile duct diameter of < 6 mm.
The mean weight and height of the participants was 51.4 kg (SD 12.25 kg) and 163.4 cm (SD 9.98 cm) respectively. The mean circumference measured at levels of chest, transpyloric plane, umbilicus and hip were 83.5 cm (SD 9.04 cm), 75.2 cm (SD 9.94 cm), 78.1 cm (SD 12.02 cm) and 87.2 cm (SD 10.0 cm) respectively.
It is an established fact that variations exist in the anthropometric features of various populations, races and regions . Studies have suggested correlation between different kinds of body builds and diseases. However, despite technological advancements, the association of anthropometric measurements with the diameters of common bile duct has remained controversial.
We did not find any statistically significant correlation of common bile duct diameter with sex. This finding was similar to other studies by Niederau et al., , Admassie , Reinus et al., , Adibi and Givechian , Brogna et al.,  and El Sharkawy E et al., .
In our study, the common bile duct did not have any significant correlation with the anthropometric measurements. Niederau et al.,  reported no correlation with height and body surface area; although the common bile duct showed correlation with weight, albeit a poor one (r = 0.11). Admassie  found positive correlation of common bile duct diameter with weight, however no such relation was found with height. However, Reinus et al.,  in his study observed no such correlation with weight.
This study was conducted among 200 normal subjects belonging to the state of Rajasthan. An equal number of males and females in the age group 18-85 years of age were included in the study. The subjects underwent ultrasonographic measurements of common bile duct diameters by experienced radiologist at the Mahatma Gandhi Medical College and Hospital at Jaipur, India. In addition, anthropometric data on weight, height, chest circumference, circumference at transpyloric plane, circumference at umbilicus and circumference at hip were obtained for each of the study subjects.
3 Regional Medical Advisor (East), GLRA-India.
Materials and Methods: Study included 200 participants with equal proportion belonging to either sex. Common bile duct was measured at three locations- at the porta hepatis, in the most distal aspect of head of pancreas and mid-way between these points. Anthropometric measurements including height, weight, chest circumference, circumference at transpyloric plane, circumference at umbilicus and circumference at hip were obtained using standard procedures.
Materials and Methods.
The lower and upper limits of normal common bile duct diameter were found to be 2.0 mm and 7.9 mm respectively in our study. However, majority of the study subjects (95%) had a common bile duct diameter of < 6 mm. The upper limit was similar to that reported in a study by Behan et al., , wherein 8 mm was recommended as the upper limit for common bile duct diameter. However, the upper limits of normality for common bile duct diameter have been reported variably by several studies. A much lower upper limit at 5 mm has been reported by some studies [13–15]. In a study by Dewbury  the range of measurements in all patients was from 2 mm to 5 mm. He therefore recommended the upper limit to be 6 mm. Among 750 adult subjects, Bruneton et al.,  found only 5.9% of to have a bile duct with a diameter greater than or equal to 5 mm. However, a high 10 mm as the normal upper limit for common bile duct diameter was reported by Wu CC et al., .
1 Demonstrator, Department of Anatomy, College of Medicine & Sagore Dutta Hospital, Kolkata, India.
[ Table/Fig-2 ] shows the distribution of common bile duct diameter by age group. The diameter was found to increase progressively from 3.9 mm among those aged 18-25 years of age to 4.7 mm among those in the age group more than 55 years of age.
Summary of correlation between common bile duct diameter and anthropometric measurements by sex.
The mean diameter of common bile duct was observed to be 4.1 mm (SD 0.95 mm) for males and 4.0 mm (SD 1.07 mm) for females. This difference was tested by applying independent samples t -test. The t value was 0.86, which was not found to be statistically significant (p = 0.38).
Height was measured using a stadiometer with a sensitivity of 0.1 centimeter. The weighing scale with a sensitivity of 0.1 kg was used to measure weight. Chest circumference was measured using a measuring tape over light clothing and while breathing normally. In the males, the measurement was made at the widest point of the chest; in the females, the measurement was made at the level of the nipples with the measuring tape held horizontally. The circumference at the transpyloric plane was measured at a level midway between the suprasternal notch (at the upper border of manubrium between the sternal heads of sternomastoid muscles) and the symphysis pubis (at the lower end of median line). Circumference at the umbilicus was obtained by measuring the abdominal circumference using measuring tape at the level of the umbilicus. Circumference at the hip was measured with the measuring tape positioned around the maximum circumference of the buttocks.
Socio-demographic details related to age, sex and place of residence were recorded for each subject. The ultrasonographic findings with regard to common bile duct diameter were obtained. In order to reduce observer bias, the same expert radiologist was involved in conducting ultrasonography for all subjects. A 3.5 megahertz (MHz) transducer was used. The common bile duct was identified through its association with the portal vein in the long axis of the gallbladder. At this location the common bile duct and hepatic artery appear as two smaller circles anterior to the portal vein, giving an appearance of a face with two ears – also called a ‘Mickey Mouse’ sign. With the indicator directed toward the patient’s right, the right ear is the common bile duct and the left ear, the hepatic artery.
We conducted this study to obtain data on sonographically measured diameters of common bile duct among Rajasthani population in order to determine the range of normal diameters for common bile duct among this population and to determine its association with age, sex, physical measurements like height, weight, chest circumference, circumference at the transpyloric plane, circumference at the umbilicus and circumference at the hip.
We found a statistically significant difference between common bile duct diameters across age groups. In addition, a linear trend was also observed with age. Several studies have reported a statistically significant correlation of common bile duct diameter with age. Niederau et al.,  found the diameter to be significantly correlated with age (r = 0.16). In a study by Kaude  the mean width of the common bile duct increased from 2.8 mm in the age group 20 years or younger to 4.1 mm in patients 71 years of age or older. Several other studies have also reported a correlation of common bile duct diameter with age [18–22].
Endoscopic retrograde cholangiography.
Zhang WJ, Xu GF, Wu GZ, Li JM, Dong ZT, Mo XD: Laparoscopic exploration of common bile duct with primary closure versus T-tube drainage: a randomized clinical trial. J Surg Res 2009, 157 (1) : e1–5. 10.1016/j.jss.2009.03.012.
Patient demographics, stone number, size, location, treatment method, duration of surgery, post-hospital stay, and treatment cost were prospectively collected. Categorical variables were presented as count, and the statistical difference between the two groups was determined by the Chi-square test. Continuous variables were expressed as mean ± standard derivation (SD) and compared with the Student’s t or the Mann–Whitney test. Statistical significance was determined by the p value less than 0.05. All analyses were carried out with Statistical Package for the Social Sciences (SPSS 12.0 for Windows, Chicago, United States).
Reasons for conversion.
Wei-jie Zhang & Wen-xian Guan.
Department of General Surgery, the Affiliated Drum tower Hospital of Nanjing University Medical School, Nanjing, 210008, China.
Because of LCBDE failure,16 cases (4.6%) required open surgery. Of 330 successful LCBDE-treated patients, 237 underwent LTSE and 93 required LC. No mortality occurred in either group. The bile duct stone clearance rate was similar in both groups. Patients in the LTSE group were significantly younger and had fewer complications with smaller, fewer stones, shorter operative time and postoperative hospital stays, and lower costs, compared to those in the LC group. Compared with patients with T-tube insertion, patients in the LC group with primary closure had shorter operative time, shorter postoperative hospital stay, and lower costs.
Healy K, Chamsuddin A, Spivey J, Martin L, Nieh P, Ogan K: Percutaneous endoscopic holmium laser lithotripsy for management of complicated biliary calculi. JSLS 2009, 13 (2) : 184–9.
Tokumura H, Umezawa A, Cao H, Sakamoto N, Imaoka Y, Ouchi A, et al .: Laparoscopic management of common bile duct stones: transcystic approach and choledochotomy. J Hepatobiliary Pancreat Surg 2002, 9 (2) : 206–12. 10.1007/s005340200020.
Laparoscopic common bile duct exploration (LCBDE) for stone can be carried out by either laparoscopic transcystic stone extraction (LTSE) or laparoscopic choledochotomy (LC). It remains unknown as to which approach is optimal for management of gallbladder stone with common bile duct stones (CBDS) in Chinese patients.
Laparoscopic common bile duct exploration was performed through either the transcystic (LTSE) approach in 237 patients (71.8%) or choledochotomy (LC) in 93 patients (28.2%). Comparison in patient demographics and clinical outcomes between LTSE and LC groups was presented in Table 4. Compared to the LC group, patients in the LTSE group were significantly younger, had smaller and fewer stones, and experienced fewer complications. Consequently, the operating time and postoperative hospital stay were significantly shorter in the LTSE than in the LC group. Therefore, the overall cost was significantly lower in the LTSE than in the LC group. However, the stone clearance rate and the frequency of conversion to open surgery were similar between the two groups. In the LTSE group, the stone removal success rate was 96.2% (228/237) and only 9 (3.8%) failed and were converted to endoscopic sphincterotomy or endosiopic papillary balloon dilation. Similarly, the stone clearance rate was 95.7% in the LC group and only 3 (4.3%) required endoscopic spincterotomy to remove stones through the sinus tract of the T-tube using a choledochoscope.
Outcome comparison between primary closure and T-tube drainage.
Dong ZT, Wu GZ, Luo KL, Li JM: Primary closure after laparoscopic common bile duct exploration versus T-tube. J Surg Res 2014, 189 (2) : 249–54. 10.1016/j.jss.2014.03.055.
Loperfido S, Angelini G, Benedetti G, Chilovi F, Costan F, De Berardinis F, et al .: Major early complications from diagnostic and therapeutic ERCP: a prospective multicenter study. Gastrointest Endosc 1998, 48 (1) : 1–10. 10.1016/S0016-5107(98)70121-X.
In the majority of LTSE patients, the cystic duct was narrow and needed to be dilated. Dilatation was carried out first with blunt, flexible dilators introduced by a 10-mm trocar inserted upright to the cystic duct opening. After dilation, a 5-mm flexible choledochoscope was introduced into the cystic duct. Small stones were flushed out through the papilla.In the majority of cases, stones were extracted with a Dormia basket (Boston Scientific Corporation, USA) under choledochoscopic control. After extraction, a completion cholangiography was performed to detect any upper bile duct stones. If the finding was negative, then the cystic duct was closed with a hem-o-lok clip (Teleflex Medical Inc, USA). Abdominal drainage was not routinely placed unles ssevere acute cholecystitis occurred.
Decker G, Borie F, Millat B, Berthou JC, Deleuze A, Drouard F, et al .: One hundred laparoscopic choledochotomies with primary closure of the common bile duct. Surg Endosc 2003, 17 (1) : 12–8. 10.1007/s00464-002-9012-6.
For the LC patients, demographic characteristics and clinical presentations of common bile duct stones were similar between the primary closure group and the T-tube drainage group. There was no statistically significant difference in stone size, number, clearance rate, and postoperative complications between the two groups. However, the endoscopic procedure time, post-operative hospital stay and cost were significantly lower in the primary closure group than in the T-tube drainage group (Table 5). In the primary closure group, the surgical success rate was 93.6% (44/47), and only 3 cases required endoscopic sphinctotomy. In contrast, the surgical success rate was 97.8% in the T-tube drainage group with only one case converted to postoperative cholangiograhy. In cases with large and impacted ampullary stones, patients were treated with percutaneous endoscopic holmium laser lithotripsy as Healy et al. describled.
Tranter SE, Thompson MH: Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct. Br J Surg 2002, 89 (12) : 1495–504. 10.1046/j.1365-2168.2002.02291.x.
Laparoscopic primary closure of CBD is safe and effective for the management of CBD stones, and can be performed routinely as an alternative to T-tube drainage[7, 19]. In our study, LC cases were randomized to either the T-tube or the primary closure groups. The the operation time and postoperative hospital stay were shorter and the hospital expenses lower in the primary closure group than in the T-tube group. We have shown fewer, but no statistical, complications in the group with the primary closure.
Trial profile and allocation of patients for LCDBE.
Wei-jie Zhang & Wen-xian Guan.
LTSE and LC with bile duct stone extraction can be performed with high efficiency, minimal morbidity and without mortality. LTSE is feasible and should be chosen as the first therapeutics, whereas LC should be restricted to large, multiple stones that cannot be extracted through the cystic duct. Postoperative T-tube drainage is unnecessary for decompression of the biliary tree.
Taylor CJ, Kong J, Ghusn M, White S, Crampton N, Layani L: Laparoscopic bile duct exploration: Results of 160 consecutive cases with 2-year follow up. ANZ J Surg 2007, 77 (6) : 440–5. 10.1111/j.1445-2197.2007.04091.x.