Common Bile Duct Stones: Leave Them Get Them or Refer Them

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Common Bile Duct Stones: Leave Them Get Them or Refer Them

  1. 1. Common Bile Duct Stones: <ul><li>Joel A. Ricci, MD </li></ul><ul><li>George Ferzli, MD, FACS </li></ul>Leave them get them… or refer them
  2. 2. Objectives <ul><li>Pre-operative identification of risk factors associated with choledocholithiasis </li></ul><ul><li>Learn different approaches in managing CBD stones </li></ul><ul><li>Intra-operative decision making according to patient’s circumstances </li></ul><ul><li>Recognize complications associated with different approaches </li></ul>
  3. 3. <ul><li>1882 Langenbuch – Cholecystectomy </li></ul><ul><li>1889 Abbe – Choledochotomy </li></ul><ul><li>1890 Ludwig Courvoisier – CBD exploration </li></ul><ul><li>1932 Mirizzi – Intraop cholangiography </li></ul><ul><li>1941 McIver – Rigid choledochoscopy </li></ul><ul><li>1957 Wild – Endoscopic ultrasound </li></ul><ul><li>1968 McCune – ERCP </li></ul><ul><li>1986 Muhe – LAP cholecystectomy </li></ul><ul><li>1991 Wallner – MRCP </li></ul>History
  4. 4. Etiology <ul><li>Point of origin: </li></ul><ul><ul><li>Secondary (gallbladder) </li></ul></ul><ul><ul><li>Primary ( de novo within biliary tract) </li></ul></ul><ul><ul><li>Primary CBD stones: </li></ul></ul><ul><ul><li>South-east asian populations </li></ul></ul><ul><ul><li>Associated with stasis and infection </li></ul></ul><ul><ul><li>Brown pigment type </li></ul></ul><ul><ul><li>Soft and easy to crumble </li></ul></ul><ul><li>Biliary stasis: </li></ul><ul><ul><li>Biliary stricture </li></ul></ul><ul><ul><li>Papillary stenosis </li></ul></ul><ul><ul><li>Sphincter of Oddi dysfunction </li></ul></ul><ul><li>Positive biliary cultures: </li></ul><ul><ul><li>Stasis </li></ul></ul><ul><ul><li>Bacterial glucoronidases </li></ul></ul><ul><ul><li>Deconjugation of bilirubin diglucuronide & precipitation of bilirubin as its </li></ul></ul><ul><ul><li>calcium salt </li></ul></ul>
  5. 5. Preoperative Suspicion <ul><li>Blood tests </li></ul><ul><li>Transabdominal ultrasound </li></ul><ul><li>ERCP </li></ul><ul><li>Endoscopic ultrasound </li></ul><ul><li>MRCP </li></ul>
  6. 6. * 600,000 cholecystectomies annually in the U.S., 8%-20% have CBD stones, no consensus on optimal management. ** “No single clinical indicator is completely accurate in predicting CBD stones prior to cholecystectomy.” * Liu, TH et al. Ann Surg 234(1), July, 2001. **Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996
  7. 7. Lezoche, E. Surg Endosc. 9(10), 1995 Liver Function Tests LIVER FUNCTION TESTS INCIDENCE OF CBD STONES NORMAL 4% One Abnormal Value 20% Three Abnormal Values 50%
  8. 8. Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996 INDICATOR SENSITIVITY SPECIFICITY CBDS on US 0.38 1.00 Cholangitis 0.11 0.99 Preop jaundice 0.36 0.97 Dilated CBD on US 0.42 0.96 Amylase 0.11 0.95 Pancreatitis 0.10 0.95 Jaundice 0.39 0.92 Bilirubin 0.69 0.88 Alk phos 0.57 0.86 Cholecystitis 0.50 0.76
  9. 9. Liu TH et al: Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangio pancreatography before laparoscopic cholecystectomy. Ann Surg 234: 33-40, 2001
  10. 10. Dilated CBD Transabdominal Ultrasound Test of choice for detecting cholelithiasis and common bile duct dilatation Low sensitivity (30%-50%) for common bile duct stones Eisen, GM. Gastrointestinal Endoscopy. 53(7), 2001.
  11. 11. SENSITIVITY 75%-100% SPECIFICITY 77%-100% Rosch, TJ Gastro Surg. 5(3), 2001 Endoscopic Ultrasound
  12. 12. Endoscopic Ultrasound STUDY N Sensitivity Specificity Edmundowicz (1992) 20 75% 100% Palazzo (1995) 422 95% 98% Prat (1996) 119 93% 97% Sugiyama (1997) 142 96% 100% Montariol (1998) 240 85% 93% Polkowski (1999) 52 91% 100% Materne (2000) 50 92% 95% Lachter (2000) 50 97% 77%
  13. 13. MRCP <ul><li>Sensitivity: 90% </li></ul><ul><li>Specificity: 100% </li></ul><ul><li>High cost </li></ul><ul><li>Limited availability </li></ul><ul><li>Non therapeutic </li></ul>
  14. 14. <ul><li>Diagnostic and therapeutic </li></ul><ul><li>Invasive study </li></ul><ul><li>Success: 99% </li></ul><ul><li>Mortality: 1% </li></ul><ul><li>Morbidity: 6% </li></ul><ul><li>Long term complications? </li></ul>Cotton, 1996 ERCP
  15. 15. ERCP <ul><li>Diagnostic and therapeutic </li></ul><ul><li>Endoscope into 2 nd portion of duodenum </li></ul><ul><li>Papilla visualized at 12 or 1 o’clock </li></ul><ul><ul><li>Small nub across semicircular folds </li></ul></ul><ul><ul><li>Soft reticulated area at tip = papillary orifice </li></ul></ul><ul><li>Cannulation of orifice </li></ul><ul><ul><li>Fluoroscopy </li></ul></ul><ul><ul><li>CBD orifice at 11 o’clock </li></ul></ul><ul><ul><li>Pancreatic duct orifice at 1 to 2 o’clock </li></ul></ul>
  16. 16. ERCP <ul><li>CBD cannulation via guidewire </li></ul><ul><li>Sphincterotomy </li></ul><ul><ul><li>Electrosurgical division of papilla </li></ul></ul><ul><li>Stone retrieval: </li></ul><ul><ul><li>Balloon sweep </li></ul></ul><ul><ul><li>Basket </li></ul></ul><ul><ul><li>Crushing technique </li></ul></ul><ul><li>Strictures: </li></ul><ul><ul><li>Cytologic brushings </li></ul></ul><ul><ul><li>Balloon dilation </li></ul></ul><ul><ul><li>Stent placement </li></ul></ul>
  17. 17. ERCP <ul><li>Complications </li></ul><ul><li>Acinarization or rupture of small ductules </li></ul><ul><li>Pancreatitis: contrast extravasation into duct </li></ul><ul><li>Cholangitis: contrast into proximal biliary tree </li></ul><ul><li>Duodenal perforation: </li></ul><ul><ul><li>Retroperitoneal or free intraperitoneal air  Emergency surgery </li></ul></ul><ul><li>Bleeding: </li></ul><ul><ul><li>Epinephrine </li></ul></ul><ul><ul><li>Electrocoagulation </li></ul></ul><ul><ul><li>Balloon tamponade </li></ul></ul><ul><ul><li>Arteriographicembolization of GDA </li></ul></ul>
  18. 18. Indicated for patients with pancreatitis and concomitant cholangitis. No indication for routine ERCP in patients with gallstone pancreatitis who will undergo cholecystectomy. SSAT, AGE, ASGE Concensus Panel. J Gastroint Surg . 5(3) 2001. ERCP
  19. 19. ERCP <ul><li>Prospective randomized trial on pts w/ resolving gallstones pancreatitis </li></ul><ul><li>34 pts had Lap chole w/ Intra-op cholangiogram </li></ul><ul><li>29 pts had preop MRCP </li></ul><ul><li>If MRCP negative  Lap chole w/ IOC </li></ul><ul><li>If MRCP positive  ERCP followed by Lap chole </li></ul><ul><li>MRCP prediction of CBD stones </li></ul><ul><ul><ul><li>Sensitivity: 100% </li></ul></ul></ul><ul><ul><ul><li>Specificity: 91% </li></ul></ul></ul><ul><ul><ul><li>Positive predictive value: 50% </li></ul></ul></ul><ul><ul><ul><li>Negative predictive value: 100% </li></ul></ul></ul><ul><ul><ul><li>Accuracy: 92% </li></ul></ul></ul>Hallal AH, et al. MRCP accurately detects common bile duct stones in resolving gallstones pancreatitis. JACS 2005;200(6):869-875 Conclusion: Patients with resolving gallstones pancreatitis and a negative MRCP do not need pre-op ERCP or Intra-op cholangiogram
  20. 20. <ul><li>Intraoperative cholangiogram </li></ul><ul><li>Laparoscopic ultrasound </li></ul><ul><li>Indocyanine green injection </li></ul>Intraoperative Suspicion
  21. 21. STATIC DYNAMIC filling defect Laparoscopic Cholangiogram
  22. 22. <ul><li>Advantages </li></ul><ul><li>Identification of biliary anatomy </li></ul><ul><li>Recognition of aberrant anatomy </li></ul><ul><li>Early recognition of CBD injury </li></ul><ul><li>Identification of CBD stones </li></ul><ul><li>Disadvantages </li></ul><ul><li>Increased OR time </li></ul><ul><li>Increased cost </li></ul><ul><li>Requires advanced technical skills </li></ul>Laparoscopic Cholangiogram
  23. 23. <ul><li>Less time consuming (<5 mn) </li></ul><ul><li>Better quality and higher resolution </li></ul><ul><li>Higher success rate (99%) </li></ul><ul><li>Possibility of interaction with the findings </li></ul><ul><li>Required for transcystic exploration of CBD </li></ul><ul><li>Limited availability </li></ul>Cuschieri 1994 Cholangiogram Dynamic
  24. 24. <ul><li>Time consuming (>16 min) </li></ul><ul><li>Film often inadequate </li></ul><ul><li>Lower success rate (47%) </li></ul><ul><li>Visualization of anatomy more difficult </li></ul><ul><li>Difficulty in differentiation between stones and air bubbles </li></ul>Cholangiogram Static
  25. 25. Cost effective analysis of intra-op cholangiogram <ul><li>Decision analytic models for cost & benefit </li></ul><ul><ul><ul><li>$100 more per routine IOC with every Lap chole </li></ul></ul></ul><ul><ul><ul><li>Routine IOC would prevent 2.5 deaths per every 10,000 pts </li></ul></ul></ul><ul><ul><ul><li>$390,000 cost per life saved </li></ul></ul></ul><ul><ul><ul><li>$87,143 cost per CBD injury avoided w/ IOC </li></ul></ul></ul>Flum DR, Flowers C, Veenstra DL. A Cost-Effectiveness Analysis of Intraoperative Cholangiography in the Prevention of Bile Duct Injury During Laparoscopic Cholecystectomy. JACS 2003;193(3):272-280
  26. 26. Current trends regarding intra-op cholangiogram <ul><li>Survey performed among 4,100 general surgeons </li></ul><ul><ul><ul><li>44% responders </li></ul></ul></ul><ul><ul><ul><li>27% defined themselves as routine IOC users </li></ul></ul></ul><ul><ul><ul><li>91% reported IOC use in >75% of Lap chole </li></ul></ul></ul><ul><ul><ul><li>Academic surgeons less prone to use (15% vs 30%) </li></ul></ul></ul><ul><ul><ul><li>Selective users more often low volume surgeons </li></ul></ul></ul><ul><ul><ul><li>Routine users more often high volume surgeons </li></ul></ul></ul><ul><ul><ul><li>“ Surgeons at greatest risk for causing common bile duct injury (inexperienced, low-volume surgeons) and those who have the greatest opportunity to train others are less likely to use IOC routinely. These represent target groups for quality-improvement intervention aimed at broader IOC use” </li></ul></ul></ul>Massarweh NN, Flum DR, et al. Surgeon Knowledge, Behavior, and Opinions Regarding Intraoperative Cholangiography. JACS 2008;207(6):821-830
  27. 27. Laparoscopic Ultrasound
  28. 28. <ul><li>Advantages: </li></ul><ul><li>Not time consuming (mean 8 min) (Santambrogio 1995) </li></ul><ul><li>Safe (Jakimowicz 1993) </li></ul><ul><li>Can be easily repeated at any stage of the operation (Rothlin 1994) </li></ul><ul><li>High success rate (~90%) (Santambrogio 1995) </li></ul><ul><li>High sensitivity (90%)and specificity (96%) (Oberlin 1994) </li></ul>Laparoscopic Ultrasound <ul><li>Disadvantages </li></ul><ul><li>Failure to recognize biliary injuries (Santambrogio 1995) </li></ul><ul><li>Increased cost </li></ul><ul><li>Requires surgeon ability in performing ultrasound </li></ul><ul><li>(Stiegman 1994) </li></ul><ul><li>Inadequate examination of the distal CBD (Santambrogio 1995) </li></ul><ul><li>Low resolution for anatomical details (Pietrabissa 1995) </li></ul>
  29. 29. Laparoscopic US as a good alternative to intraoperative cholangiography (IOC)during laparoscopic cholecystectomy:results of prospective study. <ul><li>685 IOC (-35 cannot canulate cystic duct ) , 269 LUS (-2 steatosis) </li></ul><ul><li>IOC detected 4.5% CBDS; LUS 6% </li></ul><ul><li>IOC sensitivity 96.9%, specificity 99.2% </li></ul><ul><li>LUS sensitivity 100%,specificity 99.6% </li></ul><ul><li>Results: </li></ul><ul><li>In this prospective study, LUS has been certainly as </li></ul><ul><li>effective as IOC as a primary imaging technique for bile </li></ul><ul><li>duct. It permitted to detect CBDS with a high specificity </li></ul><ul><li>and sensitivity, and was not followed by an increase in </li></ul><ul><li>CBDI. </li></ul>Hublet A et al Laparoscopic US as a good alternative to intraoperative cholangiography during lap chole: results of prospective study ActaChir Belg . 2009 May-Jun Belgique.
  30. 30. Assessment of CBD using laparoscopic US during laparoscopic cholecystectomy <ul><li>115 consecutive patients, LUS successful in112. </li></ul><ul><li>Low risk 7%; Intermediate 36.4%; High risk 78.9%. </li></ul><ul><li>With increasing experience, LUS can become the </li></ul><ul><li>routine method for evaluating the bile duct during </li></ul><ul><li>LC. A more aggressive preoperative evaluation of </li></ul><ul><li>CBD is mandated in the intermediate and high risk </li></ul><ul><li>groups of patients suspected of having CBD stones. </li></ul>YAO CC et al Assessment of common bile duct using laparoscopic US during laparoscopic cholecystectomy Surg Laparosc Endosc Percut Tech 2009 Aug Taiwan.
  31. 31. Intraoperative cholangiography in combination with laparoscopic ultrasonography for the detectection of occult choledocholithiasis <ul><li>103 patients IOC+LUS. Physicians team blinded. </li></ul><ul><li>Success rate : IOC 91.3%; LUS 100% </li></ul><ul><li>Time required for LUS was shorter. </li></ul><ul><li>The sensitivity of IOC combined with LUS was 92.9% which was greater than of IOC and LUS taken separately. </li></ul><ul><li>LUS is usually performed in case where IOC has failed or is </li></ul><ul><li>contraindicated. The combination of both methods maximizes </li></ul><ul><li>intraoperative detection of occult CBD stones and should at least </li></ul><ul><li>be recommended as two complementary methods. </li></ul>LI JW et al Intraoperativecholangiogram in combination with laparoscopic us for the detection of occult choledocholithiasis Med SciMonit. 2009 Sept China
  32. 32. Indocyanine Green (ICG) Injection: <ul><li>Shows the confluence between right and left hepatic </li></ul><ul><li>ducts during hepatectomy </li></ul><ul><li>Enables identification of the cystic duct and CBD </li></ul><ul><li>from before dissection of Calot’s triangle during </li></ul><ul><li>cholecystectomy </li></ul>Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009; 208(1):e1-e4
  33. 33. Indocyanine Green Injection (ICG) Advantages <ul><ul><li>No need for dissection of Calot’s triangle </li></ul></ul><ul><ul><li>No need for insertion of trans-cystic tube </li></ul></ul><ul><ul><li>No exposure to radiation </li></ul></ul><ul><ul><li>No space-occupying C-arm machine required </li></ul></ul><ul><ul><li>Simple and convenient procedure </li></ul></ul><ul><ul><li>Allergic reactions </li></ul></ul>Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;208(1): e1-e4
  34. 34. Intra-operative Decision Making <ul><li>Convert to open? </li></ul><ul><li>Laparoscopic transcystic common bile duct exploration? </li></ul><ul><li>Laparoscopic cholechotomy? </li></ul><ul><li>Defer to post-op management? </li></ul><ul><li>Open or laparoscopic biliary bypass? </li></ul><ul><li>Transduodenal papillotomy? </li></ul><ul><li>Combined laparoscopy + ERCP? </li></ul>
  35. 35. Factors influencing approach to the common bile duct Factor Transcystic Choledochotomy One stone + + Multiple stones + + Stones < 6mm + + Stones > 6mm - + Intra-hepatic stones - + Cystic duct < 4mm - + Cystic duct > 4mm + + CBD < 6mm + - CBD > 6mm + + CD entrance: lateral + + Entrance: posterior - + Entrance: distal - + Mildly inflamed + + Markedly inflamed + - Suturing: poor + - Suturing: good + +
  36. 36. <ul><li>Transcystic: </li></ul><ul><li>Stone < 6 mm </li></ul><ul><li>Cystic duct > 4 mm </li></ul><ul><li>CBD < 6 mm </li></ul><ul><li>Lateral entrance of cystic duct </li></ul><ul><li>Severe or mild inflammation </li></ul><ul><li>Poor suturing ability </li></ul>1998, Petelin Laparoscopic CBD Exploration <ul><li>Transductal: </li></ul><ul><li>Stone > 6 mm </li></ul><ul><li>Cystic duct < 4 mm </li></ul><ul><li>CBD > 6 mm </li></ul><ul><li>Posterior or distal entrance of cystic duct </li></ul><ul><li>Mild inflammation </li></ul><ul><li>Good suturing ability </li></ul>
  37. 37. Transcystic Approach
  38. 38. Transcystic Approach STUDY N SUCCESS (%) FERZLI, 1991 13 100 SAGES, 1994 187 95 PHILLIPS, 1994 111 91 DePAULA, 1994 102 84 BERTHOU, 1994 78 67 McGRATH, 1994 44 93 DION, 1994 18 94 STOKER, 1995 33 94
  39. 39. Laparoscopic Choledochotomy
  40. 40. Laparoscopic Choledochotomy
  41. 41. Complications of Lap. CBD Exploration
  42. 42. Techniques <ul><li>Irrigation: </li></ul><ul><li>Transcystic flushing </li></ul><ul><li>IV glucagon </li></ul><ul><li>Fluoroscopic monitoring </li></ul><ul><li>Balloon: </li></ul><ul><li>4 Fr Fogarty balloon combined with choledochoscope </li></ul><ul><li>Basket: </li></ul><ul><li>Avoid capture of papilla of Vater </li></ul><ul><li>Choledocoscopy / completion cholangiogram </li></ul><ul><li>Primary closure of CDB vs T-tube placement </li></ul>
  43. 43. Combined Laparoscopy and ERCP <ul><ul><ul><li>45 pts underwent lap chole w/ intra-op cholangiogram </li></ul></ul></ul><ul><ul><ul><li>33 pts had succesful intra-op ERCP with extraction of CBD stones </li></ul></ul></ul><ul><ul><ul><li>No post-op complications related to procedure (i.e. pancreatitis </li></ul></ul></ul><ul><ul><ul><li>bleeding, perforation) </li></ul></ul></ul><ul><ul><ul><li>Mean hospital stay: 2.55+0.89 days </li></ul></ul></ul><ul><ul><ul><li>No pts w/ signs or symptoms of retained CBD stones during mean post-op follow-up of 9+4.07 months </li></ul></ul></ul>Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7(4):338-46
  44. 44. Current Trends <ul><li>National Hospital Discharge Survey database 1979 to 2001: </li></ul><ul><li>Frequency of ERCP vs CBDE </li></ul><ul><li>Beginning of study: 47,000 CBDE’s per year </li></ul><ul><li>End of study: 7,000 CBDE vs 43,000 ERCP </li></ul><ul><li>Complication rates from CBDE </li></ul><ul><ul><li>3.4% at beginning of study </li></ul></ul><ul><ul><li>17.4 at end of study </li></ul></ul><ul><ul><li>“ ERCP has replaced the need for most but not all CBDE” </li></ul></ul><ul><ul><li>“ Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CBDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CBDE experience” </li></ul></ul>Livingstion EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433
  45. 45. Drainage Procedures <ul><li>Indications: </li></ul><ul><ul><li>Multiple CBD stones </li></ul></ul><ul><ul><li>Recurrent choledocholithiasis </li></ul></ul><ul><ul><li>Unsuccessful sphincterotomy </li></ul></ul><ul><ul><li>Impacted large CBD stones </li></ul></ul><ul><ul><li>Markedly dilated CBD </li></ul></ul><ul><li>Choices: </li></ul><ul><li>Choledochoduodenostomy </li></ul><ul><li>Transduodenal sphincteroplasty </li></ul><ul><li>Choledochojejunostomy </li></ul>
  46. 46. Cost <ul><li>Hospital cost in management of CBD stones </li></ul><ul><ul><ul><li>53 pts underwent one-stage or two-stage procedure for CBD stone </li></ul></ul></ul><ul><ul><ul><li>One stage: Lap CBD exploration + lap chole </li></ul></ul></ul><ul><ul><ul><li>Two stage: ERCP followed by lap chole </li></ul></ul></ul><ul><ul><ul><li>38 pts underwent cost analysis due to uneventful post-op course </li></ul></ul></ul><ul><ul><ul><li>Hospital stay: </li></ul></ul></ul><ul><ul><ul><ul><li>One stage: 2 (0-6) days </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Two stage: 8 (3-18) days </li></ul></ul></ul></ul><ul><li>Significantly lower costs after one-stage approach </li></ul><ul><li>Total hospital cost: 2,636 vs 4,608 euro </li></ul><ul><li>Hospitalization cost: 701 vs 2,190 euro </li></ul><ul><li>Pharmaceutics cost: 645 vs 1,476 euro </li></ul><ul><li>Para-medic personnel: 1,035 vs 1,860 euro </li></ul><ul><li>OR cost (comparable): 1,278 vs 1,232 euro </li></ul>Topal B et al. Hospital cost categories of one-stage versus two-stage management of common bile duct stones. SurgEndosc 2009 Jun 25. [Epub ahead of print]
  47. 47. Postoperative Management <ul><li>Post-op ERCP </li></ul><ul><li>Lithotripsy </li></ul><ul><ul><li>Mechanical (crushing technique) </li></ul></ul><ul><ul><li>Extra-corporeal shock wave (electromagnetic) </li></ul></ul><ul><ul><li>Intra-corporeal (laser) </li></ul></ul><ul><li>Percutaneous radiologic </li></ul><ul><li>Dissolution (chemical infusion) </li></ul><ul><ul><li>Mono-octanoin </li></ul></ul><ul><ul><li>Methyl tert -buthyl ether (MBTE) </li></ul></ul><ul><li>Ursodeoxycolic acid </li></ul><ul><ul><li>Prevention </li></ul></ul>
  48. 48. Treatment of difficult bile duct stones: a particularly safe option for octogenarians <ul><li>Ten years (1995-2006) : 44 patients median age 80. </li></ul><ul><li>Success in 34 (77%). The others required multiple attempts. All but one achieved complete clearance. </li></ul><ul><li>Peroral endoscopic electrohydrolic lithotripsy(EHL) or </li></ul><ul><li>laser lithotripsy (ILL), under direct cholangioscopic </li></ul><ul><li>visualisation, is an effective treatment for difficult CBD </li></ul><ul><li>stones. The technique can be used safely even in frail </li></ul><ul><li>and elderly patients. The vast majority of patients may </li></ul><ul><li>be expected to remain symptom-free for a prolonged </li></ul><ul><li>period. </li></ul>Swahn F et al Ten Years of Swedish experience with intraductal electrohydrolic lithotripsy (EHL) and laser lithotripsy (ILL) for the treatment of difficult bile duct stones: an effective and safe option for octogenarians Surg Endosc. 2009 Oct 23
  49. 49. Extracorporeal shock wave lithotripsy: analysis of factors that favor stone fragmentation <ul><li>A high success rate, negligible complications and </li></ul><ul><li>non-invasive nature of the procedure make ESWL a </li></ul><ul><li>useful tool for removing large CBD stones </li></ul>Tandan M et al Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: efficacy and analysis of factors that favor stone fragmentation J Gastroenterology Hepatol . 2009 Aug India. 283 patients with large CBDS were subjected to ESWL . CBDS were Fragmented to 5mm or less then extracted via ERCP. Complete clearance achieved in 239 patients(84.4%),partial in 35 (12.3%)
  50. 50. Risk factors for recurrent bile duct stones after endoscopic clearance of CBD stones <ul><li>114 patients (2004-2007) S/P ERCP. </li></ul><ul><li>The recurrence of CBD stones was more commonly </li></ul><ul><li>found in the patients group with type 1 periampullary </li></ul><ul><li>diverticulum and multiple sessions of ERCP. </li></ul><ul><li>Therefore, patients with these risk factors should be </li></ul><ul><li>on regular follow up. </li></ul>Baek YH et al Risk factors for recurrent bile duct stones after endoscopic clearance of common bile duct stones Korean J Gastroenterol . 2009 Jul Korea.
  51. 51. Conclusion <ul><li>Multidisciplinary approach to CBD stones </li></ul><ul><li>Pre-operative identification based on risk factors </li></ul><ul><li>Laparoscopic CBD exploration is safe, cost-effective and carries low morbidity and mortality rate </li></ul><ul><li>Surgeon experience determines: </li></ul><ul><ul><li>Lap vs Open approach </li></ul></ul><ul><ul><li>Type of drainage procedure if necessary </li></ul></ul>LAP. CHOLE + CBD STONE ERCP skills Availability of equipment Technical skills
  52. 53. What to do? ERCP MRCP Lap CBD LUS Lap Cholangiogram Transcystic CBD Lap Chole
  53. 54. PREOP INTRAOP POSTOP Sono EUS MRCP ERCP Lap transcystic Lap CBD Open CBD ERCP Conclusion
  54. 55. Transcystic Exploration <ul><li>Laparoscopic vs Open </li></ul><ul><ul><li>Stones larger than duct  Dilatation </li></ul></ul><ul><ul><li>Irrigation </li></ul></ul><ul><ul><li>Fluoroscopic wire basket </li></ul></ul><ul><ul><ul><li>Stones smaller than 2 to 4 mm </li></ul></ul></ul><ul><ul><ul><li>Clockwise rotation while retracting basket </li></ul></ul></ul><ul><ul><ul><li>Care not to pull stones into hepatic ducts </li></ul></ul></ul><ul><ul><li>Endoscopic approach </li></ul></ul><ul><ul><ul><li>Choledochoscopebasketing </li></ul></ul></ul><ul><ul><li>Long, spiraling, medially inserting cystic duct </li></ul></ul><ul><ul><ul><li>Choledochotomy </li></ul></ul></ul>
  55. 56. <ul><li>08% Normal exam </li></ul><ul><li>33% CBD stones </li></ul><ul><li>25% Biliary injury </li></ul><ul><li>100% Success for stone removal </li></ul><ul><li>86% Success for biliary injuries </li></ul><ul><li>05% Complication </li></ul>Kozarek, Surg Endosc 1995 Nov;9(11):1235-40 ERCP
  56. 57. Postoperative ERCP
  57. 58. WHAT TO DO? ERCP lap CBD EUS IOC MRCP Lap US
  58. 59. Choledochotomy <ul><li>Laparoscopic vs Open </li></ul><ul><li>Large stones: > 1cm </li></ul><ul><li>Anterior wall dissection 1-2 cm distance </li></ul><ul><li>Stay sutures bilaterally </li></ul><ul><li>Vascular supply @ 3 and 9 o’clock </li></ul><ul><li>Longitudinal incision anterior aspect </li></ul><ul><li>Choledochoscope inserted </li></ul><ul><li>Irrigation, basket retrieval, lithotripsy </li></ul><ul><li>12 or 14 Fr T-tube positioned </li></ul><ul><li>CBD closure over T-tube </li></ul><ul><li>Primary closure of CBD </li></ul><ul><li>Completion cholangiogram </li></ul>

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