The document discusses the management of choledocholithiasis or common bile duct stones. It covers the clinical features, investigations like ultrasound, CT, ERCP and MRCP. It discusses the diagnostic approach and various management options including endoscopic procedures like ERCP with sphincterotomy and plastic stent placement. It also discusses open CBD exploration techniques like choledochotomy and T-tube placement. Laparoscopic CBD exploration is mentioned as a minimally invasive method. Guidelines recommend ERCP as first-line treatment for CBD stones with timing based on severity of cholangitis. Sphincterotomy with balloon dilation and cholangioscopy-assisted lithotripsy are suggested for difficult stones.

1. MANAGEMENT OF
CHOLEDOCHOLITHIASIS
Sushil Gyawali
MS resident

2. INTRODUCTION:
• Common bile duct (CBD) stones are identified in 10 to 15 percent of patients
undergoing surgery for symptomatic cholelithiasis.
• Choledocholithiasis most frequently result from the migration of gallstones
from the gallbladder into the biliary tree.
• Choledocholithiasis is the leading cause of acute pancreatitis.
Frossard JL, Morel PM. Detection and management of bile duct stones. Gastrointest
Endosc 2010;72:808-16

3. CBD stones
• On the basis of point of origin:
1. Primary stones :
• Arise de novo in the bile duct
• Brown pigment type
• Associated with biliary stasis and infection
• More in Asians.
2. Secondary stones:
• Formed within the gallbladder and migrate down the cystic duct to the
common bile duct
• Cholesterol stones

4. Clinical Features
• Asymptomatic
• Biliary colic
• Obstructive jaundice
• Scleral icterus, darkening of urine, lightening of stools, pruritus
• RUQ pain
• waxing and waning symptoms
• CharcotTriad
– ascending cholangitis
• Reynolds Pentad
• acute obstructive cholangitis ( suppurative cholangitis)
• Pancreatitis

5. Courvoisier's law
• In the presence of a palpably enlarged gallbladder which is non-
tender and accompanied with mild painless jaundice, the cause is
unlikely to be gallstones.
• Exceptions:
 Double gallstones with one falling and blocking the common bile duct (responsible
for jaundice) and one at the cystic duct (palpable non-tender gallbladder results
from precisely a mucocele of the fibrotic gallbladder.
 Flukes in the cystic duct and cbd

6. Investigations
• CBC:
• With superinfection, leucocytosis
• LFT:
• Conjugated hyperbilirubinemia
• RaisedALP
• S. Amylase
• S. Lipase
• PT/INR

7. Ultrasound Abdomen/Pelvis
• May show
• CBD stones or
• only biliary dilation/CBD dilated
• Dilated bile duct > 6 mm
• Dilated bile ducts in presence of
gallstones highly suggestive.
• Sensitivity:
• Specificity:

8. Predictors of choledocholithiasis:

9. CECT Abdomen Pelvis
• The most sensitive investigation forCBD stones.
• Shows stones, location, stricture/blockage, dilatation.
• May show associated mass/tumor other pathology.

11. ERCP
• Highly sensitive and
specific
• Diagnostic and
Therapeutic role
• Indications:
• CBD stone removal
• Cholangitis
• Biliary pancreatitis
• Multiple comorbidities
• Limited experience

12. MRCP
• Highly sensitive (>90%), ~100%
specificity
• Noninvasive
• Uses water in bile to delineate
the biliary anatomy.
• Accurate imaging of the biliary
tree
• Non therapeutic

13. EUS
• More sensitive and specific
• Invasive
• Valuable in the assessment of the distal CBD and ampulla.

14. PTC
• Invasive
• Effective with dilated biliary ductal system.
• Indicated in those with failed ERCP.
• Therapeutic
• Peroperative Cholangiography:
• Pain at time of operation
• Abnormal LFT
• Dilated biliary tree
• Anomalous or confusing biliary anatomy, suspected injury
• Inability to perform postop ERCP eg Roux enY bypass
• Any suspicion of CBD stone eg palpable CBD stone

15. Diagnostic approach:

17. Management options:

18. Endoscopic procedures:
Endoscopic Retrograde Cholangioscopy followed by endoscopic sphincterotomy has
become the most widely used method for imaging and treating CBD stones.

19. ERCP
The technique consists of the
endoscopic identification of the papilla
major (Vater papilla), its cannulation in
order to perform ERC and endoscopic
sphincterotomy followed by CBDS
extraction by Dormia Basket or balloon

20. ERCP
• Endoscopic sphincterotomy success rate is reported to exceed 90%.
• Although regarded widely as a safe procedure, large series have recently shown
5%-9.8% morbidity and 0.3% to 2.3% mortality, mostly due to postoperative
acute pancreatitis, bleeding and perforation.
• Balloon and basket catheters are equally effective and safe for common bile
duct stone removal

21. • Endoscopic placement of a
temporary biliary plastic stent in
patients with irretrievable biliary
stones that warrant biliary
drainage
• Plastic stent placed because of
incomplete common bile duct
stone clearance should be
removed or exchanged within 3 –
6 months to avoid infectious
complications

22. Therapeutic algorithm for Endoscopic management:

23. Timing of ERCP:
• Preoperative ERCP:
• Need of a second surgical procedure to treat gallstones
• Allowing for a “strategy update” before surgery
• If endoscopic sphincterotomy is successful, cholecystectomy will complete
the mini-invasive management.
• if it is not, the “second step” will be a surgical procedure aimed at
managing both gallstones and CBDS.
• Post-cholecystectomy ERCP:
 “two step management” of cholecysto-choledochal lithiasis
 Great advantage of performing ERC in virtually only those cases really needing
CBD clearance
 Drawback is the need for a third surgical procedure whenever postoperative ERC
fails.
The rendezvous technique involves CBDS diagnosis and the synchronous
management of both gallstones and CBDS during the same procedure (“one step”)

24. Open CBD exploration:
• The preferred approach to CBD exploration is typically through a
supraduodenal choledochotomy,
• The transduodenal/ transampullary route reserved for patients with impacted stones
that cannot be removed readily from above.
• Clearance of the biliary tree should be confirmed by performing
postexploratory choledochoscopy / cholangiography.
• The selective use of biliary-enteric drainage procedures

25. The gallbladder is usually removed before exploration of the CBD because it may obstruct vision,
although in some cases it can be a useful aid to retraction.
Palpation of the CBD and handling of its lower part during exploration and subsequent
choledochoscopy cannot be done properly without having performed a classic Kocher maneuver

26. Choledochotomy:

27. Exploration of the duct:
• The catheter is passed into the duodenum.
• The balloon is inflated, and the catheter is withdrawn until it
impinges against the papilla.
• The balloon is identified in the second part of the duodenum by
palpation. Stones can usually be felt against the shaft of the
catheter within the duct.
• The balloon is deflated and gently withdrawn through the papilla,
and then the balloon is reinflated immediately.
• Passage back through the ampulla can be detected by a sudden
easing of the pull on the catheter.
• the catheter is gradually pulled up to the choledochotomy site.

28. Primary closure of the CBD
• Primary closure of the CBD after exploration can be done only if certain criteria
such as the following are satisfied:
• Patent ampulla ofVater
• Complete removal of all intraductal calculi
• Absence of pancreatic pathology
• Meticulous suture of the duct
(Dehiscence of the suture line would be detected late in the absence of a drain
leading to advanced biliary peritonitis by the time it is diagnosed.The mortality of
this condition is very high. Hence, primary closure of the CBD has to be done
judiciously.)

29. T-tube placement:
T tube allows drainage of bile in the setting of CBD or
papillary edema and access for postoperative stone
retrieval or cholangiography or choledochoscopy.
Disadvantages include tube migration, obstruction,
and bile leak following removal.
The T-tube is prepared by cutting two limbs at
lengths that will not traverse into the left or
right hepatic duct proximally or into
the duodenum distally, and by excising the back
wall of the horizontal portion of the T (to minimize
the risk of tube occlusion and to facilitate tube
removal).
The tube is inserted through the choledochotomy,
and the remainder of the duct is closed with fine
absorbable sutures around the tube

30. T-tube management;
Initially, bile is allowed to drain freely
into a bile bag to allow any spasm or
edema of the sphinc-ter to settle
before testing the suture line of the
choledochotomy.
Once it appears that bile is flowing
into the duodenum, a T-tube
cholangiogram can be taken about 5
to 7 days postoperatively.
If it appears normal, the tube is
removed on day 7 or 8 by gentle
traction

31. T-tube:
• If persistently elevated output or drainage
around the tube occurs, investigation via
cholangiography can identify malfunction,
dislodgement, or distal obstruction secondary to
retained stone.
• If a repeat cholangiogram at approximately 2 to
3 weeks is normal, the T-tube may be removed. If
choledocholithiasis persists, the T-tube can be
clamped to promote stone passage.
• If signs or symptoms of cholangitis occur, the
tube can be unclamped and repeat imaging is
obtained. Residual obstruction may be amenable
to stone extraction via T-tube or endoscopic or
percutaneous access.

32. Laparoscopic CBD exploration:
• Cost effective, efficient and minimally invasive method of treating
choledocholithiasis.
• Combined LC and intra-operative laparoscopic bile duct exploration (LCBDE):
• Safe and effective for removal of CBD stones.
Single-stage LCBDE is superior to ERCP + LC in terms of technical success
and shorter hospital stay in good-risk patients with gallstones and CBD
stones, where expertise, operative time and instruments are available.
(Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone
extraction followed by laparoscopic cholecystectomy for patients with gallbladder stones with common bile duct stones:
systematic review and meta-analysis of randomized trials with trial sequential analysis.
Singh AN, Kilambi R. Surg Endosc. 2018 Sep;32(9):3763-3776)

33. Laparoscopic CBD exploration

34. • The stones can be retrieved by
• Spontaneous evacuation while incising the bile duct
• Blunt instrumental pressure with atraumatic forceps and milking,
• Dormia basket, Fogarty balloon catheter or irrigation

35. New Guideline on Management of
Common Bile Duct Stones ( ESGE)
Douglas G. Adler, MD, FACG, AGAF, FASGE reviewing Manes G et al. Endoscopy 2019
Apr 3
• Diagnosis:
• Obtain liver function tests and abdominal ultrasonography as first
diagnostic steps for suspected CBDS.
• If abdominal ultrasound results do not confirm suspected CBDS, perform
endoscopic ultrasonography or magnetic resonance
cholangiopancreatography (MRCP).

36. • Treatment
• Offer stone extraction to all patients with CBD Stones who are fit enough to
tolerate interventions, regardless of whether they have symptoms.
• In patients with acute cholangitis, perform endoscopic drainage as first-line
therapy, with timing based on severity of disease as follows:
• Severe: within 12 hours in patients with septic shock
• Moderate: within 48–72 hours
• Mild: elective
• Place a temporary biliary plastic stent when biliary drainage is needed in
patients with unextractable stones.

37. • Perform a limited sphincterotomy combined with endoscopic papillary large-
balloon dilation (EPBD) as the first-line technique to remove difficult CBD
Stone.
• Using cholangioscopy-assisted techniques to perform lithotripsy
(electrohydraulic or laser) is safe and effective for treating difficult CBDS.
• Perform laparoscopic cholecystectomy within 2 weeks following ERCP for
choledocholithiasis to reduce risk for future biliary-related disease.

38. THANKYOU

39. Literature review:

40. Literature review:
Open bile duct surgery seems superior to ERCP in achieving common bile duct stone
clearance based on the evidence available from the early endoscopy era.
There is no significant difference in the mortality and morbidity between laparoscopic
bile duct clearance and the endoscopic options.There is no significant reduction in the
number of retained stones and failure rates in the laparoscopy groups compared with
the pre-operative and intra-operative ERCP groups.

41. Literature review:

42. Literature review: