Introduction: Symptoms of choledocholithiasis can appear after cholecystectomy. Stones diagnosed during the first two years following surgery are assumed to have been present at the time of surgery. The purpose of this study was to study patients who presented with choledocholithiasis at Landspitali - The National University Hospital of Iceland, during the period 2008-2011, who had previously undergone cholecystecomy and to assess whether cholodocholithiasis is underdiagnosed at the time of cholecystectomy.

Material and methods: The study was retrospective, data was collected from medical records at Landspitali. Among recorded data were liver function tests, imaging results, time from surgery to diagnosis, treatment and complications.

Results: Forty patients presented with choledocholithiasis after previous cholecystectomy. Mean age was 50 years (20-89) and women were 24 (60%). Mean time from surgery to diagnosis was 382 days. Diagnosis was confirmed with imaging in 35 (87.5% cases). Thirty six (90%) patients were treated with ERCP, one with PTC and one underwent open surgery. Three patients healed without treatment. Three patients developed complications from treatment. Thirty one (77.5%) had choledocholithiasis in the first 2 years following surgery. Incidence of previous choledocholithiasis, elevated bilirubin or widening of the choledochus without visible stones where similar for those diagnosed with choledocholithiasis in the first two years and those diagnosed later.

Conclusion: Majority of patients are treated without surgery. Most stones are diagnosed during the first two years following surgery. For the majority of cases it can not be concluded that stones should have been suspected at time of cholecystectomy.

Pictures and tables

Picture 1. Kaplan-Meyer graph showing time from  cholecystectomy to diagnosis of common bile duct stones. X-axis is time and number of patients on Y-axis. About ¾ of patients (77.5%) are diagnosed in the first 2 years following surgery.

Table I : Comparison of patients diagnosed with choledocholitiasis before and after 2 years from cholecystectomy.

	Diagnosis <2 years (n=31) n (%)	Diagnosis  ≥ 2 ár (n= 9) n (%)
Mean age (years)	48	53
Choledocholithiasis before cholecystectomy	4 (12.9%)	3 (33.3%)
Bilirubin >25	3 (9.7%)	1 (11.1%)
Widening of the choledocus without visible stones	2 (6.5%)	2 (22.2%)
ERCP before surgery	5 (16.1%)	4 (44.4%)
Papillotomy	3 (9.7%)	3 (33.3%)
Intraoperative cholangiogram	5 (16.1%)	4 (44.4%)
Repeated choledocholithiasis	6 (19.4%)	1 (11.1%)

Picture 2. Treatment of patients with choledocholithiasis.