A stone in the bile duct is like the Queen of Spades in the card game Black Maria: you get rid of it at all costs. If a stone is found when the gallbladder is being removed it can be removed at that time. If the stone is found after the operation the surgeon may leave the T-tube drain in place. After about six weeks the track of the T-tube is used to steer a basket up to the stone, which can be ensnared and pulled out through the skin.
Another way of removing a stone in the bile duct soon after surgery is to inject a liquid, which dissolves cholesterol, through the T-tube. After a few days many of the smaller stones at the bottom of the bile duct are dissolved away or made smaller so that they pass on their own. The usual treatment is to inject a drug called mono-octanoin, but other drugs are being tested as well.
Half of the stones 7 mm or less across can be dissolved by this method and sometimes larger stones as well.
Catching stones in a basket
Another way is to attack the problem from the other end. You swallow on instrument called a Flexible Fibreoptic Endoscope. The end is passed into the duodenum (small intestine) and through the instrument a wire is passed which can be made “electrically” live to cut or widen the entrance to the bile duct.
Stones in the bile duct can then be taken out by catching them in a wire basket or passing a tube with a balloon on the end of it up the bile ducts, blowing it up above the stone, and then dragging it down. Sometimes just making the cut in the entrance makes it wide enough for stones to pass out on their own.
Can’t take an anaesthetic ?
In people who cannot have a general anaesthetic, bile duct stones may be removed by the endoscope, even when the gallbladder is still in place with stones in it. If stones cannot be removed completely at the time it is possible to place a fine plastic tube in the bile duct with the end above the stone and bring the other end out through the duodenum, stomach, gullet, and nose. A drug, mono-octanoin, can be carefully injected to dissolve away stones. Another treatment is to take bile acids orally. This will eventually dissolve about half the non-chalky common bile duct stones, but it does take a long time.