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Cbd stones

Cbd stones

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Cbd stones

  1. 1. Biliary stone diseases Mathew Philip PVS Memorial hospital Kochi
  2. 2. Prevalence of gallstones by age and gender
  3. 3. Introduction  Eleven to 21% of cholelithiasis have concomitant CBDS at the time of surgery  Majority of CBDS form in GB and then migrate CBD  Pass into the duodenum following the bile flow  May remain in the choledochus owing to the smaller diameter at the Vater papilla
  4. 4. Clinical presentation  Asymptomatic  Colicky pain  Cholecystitis  Biliary obstruction  Ascending cholangitis  Acute Biliary pancreatitis
  5. 5. CBD stones - Endotherapy  Diagnosis  US,MRCP, EUS and ERC  Endoscopic retrograde cholangiography (ERC) changed the approach to CBDS
  6. 6. Role of EUS  Diagnosis of CBDS  Comparable to MRC  More sensitive for  Biliary microcalculi  Small stone impaction at ampulla  Biliary sludge  Reduce ERC interventions
  7. 7. Outline  Standard treatment of CBD stones  Define Difficult Bile duct stone  Factors associated with difficult CBD stones  Treatment strategies of difficult CBD stones
  8. 8. Outline  Standard treatment of CBD stones  Define Difficult Bile duct stone  Factors associated with difficult CBD stones  Treatment strategies of difficult CBD stones
  9. 9. Standard treatment of CBD stnes
  10. 10. Standard Treatment of CBD stones
  11. 11. Outline  Standard treatment of CBD stones  Define Difficult Bile duct stone  Factors associated with difficult CBD stones  Treatment strategies of difficult CBD stones
  12. 12. Difficult CBD Stone  Commonly refers to a stone > 15 mm in diameter  Usually unable to make ES larger than 15 mm  Stones < 15 mm may be considered difficult if:  Proximal to stricture  Narrow intrapancreatic segment  Impacted  Multiple  Intrahepatic  Billroth II reconstruction  ES length is limited – e.g., periampullary diverticulum
  13. 13. Outline  Standard treatment of CBD stones  Define Difficult Bile duct stone  Factors associated with difficult CBD stones  Treatment strategies of difficult CBD stones
  14. 14. The variables affecting the success of stone extraction  Stone size and shape  Bile duct diameter  Bile duct geometry  Composition of the stone  Bile duct strictures distal to the stone
  15. 15. Endoscopic technical difficulty of CBD Stones  Older age (>65 years)  Previous gastrojejunostomy  Larger CBD stone (≥ 15 mm)  Impacted CBD stone  Use of mechanical lithotripsy  Short length of the distal CBD arm (<36mm)  Acute distal CBD angulation (<135 degrees)  Relative narrowing of distal CBD GIE 2007; 66:1154-60
  16. 16. Reasons for unsuccessful CBD stone removal  Anatomic obstacles to cannulation  Postoperative states  Billroth II gastroenterostomy  Roux-en-Y anastomosis  Anastamotic strictures  Ampullary or duodenal tumor mass  Scared duodenum from prior PUD  Periampullary diverticulum  Ampullary edema or inflammation
  17. 17. Outline  Standard treatment of CBD stones  Define Difficult Bile duct stone  Factors associated with difficult CBD stones  Treatment strategies of difficult CBD stones
  18. 18. Principle for treatment Difficult biliary stone  Decrease stone size  Larger CBD orifice
  19. 19. Principle for treatment Difficult biliary stone  Decrease stone size  Larger CBD orifice
  20. 20. Endoscopic Management of Large Bile Duct Stones  Mechanical lithotripsy  Intraductal shockwave lithotripsy  Electrohydraulic  Laser  Extracorporeal shockwave lithotripsy  Dissolution  MTBE  Monooctanoin  Long term stents
  21. 21. Endoscopic Management of Large Bile Duct Stones  Mechanical lithotripsy  Intraductal shockwave lithotripsy  Electrohydraulic  Laser  Extracorporeal shockwave lithotripsy  Dissolution  MTBE  Monooctanoin  Long term stents
  22. 22. Mechanical lithotripsy  Integrated  Salvage
  23. 23. Mechanical Lithotripsy  Advantages  Relatively easy to use  Relatively low cost  Prevents stone impaction  Can be done at initial ERCP  Disadvantages  Requires stone capture  Very hard stones may not fragment  Several baskets may be required for each patient
  24. 24. Soehendra Mechanical Lithotriptor
  25. 25. Mechanical lithotripsy- Salvage
  26. 26. Principle for treatment Difficult biliary stone  Decrease stone size  Larger CBD orifice
  27. 27. Large Balloon Dilatation of Sphincter
  28. 28. Bile Duct Stones Failed Mechanical Lithotripsy ESWL Percutaneously Surgery Cholangioscope - Laser - EHL Stent Dissolve
  29. 29. Cholangioscope  Mother baby scope  Two operators  Fargile  High repair costs  No dedicated irrigation channel  Limited two way steering capability  Spyglass  Single operator  Four way steering capability  Independent irrigation channel  Diagnostic and therapeutic capabiities
  30. 30. Mother-Baby Scope System
  31. 31. Spyglass
  32. 32. Spyglass 10 Fr catheter Guidewire Optical fiber Direction dials + locks Irrigation port
  33. 33. Cholangioscopy and Stone fragmentation
  34. 34. Endoscopic management of Calculous cholecystitis  Comorbidities  Elderly  Trans papillary GB stenting / drainage  EUS guided cholecystoduodenostomy
  35. 35. Conclusions  Biliary lithiasis affects 10% to 20% of general population  CBDS in up to 20%  Endoscopic removal successful in 80-90% using standard techniques  EUS has an important role and avoids unnecessary ERC
  36. 36. Conclusions  Stone location, stone size, and bile duct features may render stones non extractable using standard retrieval techniques  Balloon sphincteroplasty helps in extracting bigger stone  Difficult stones mechanical lithotripsy is easiest and cheapest, if stone can be captured in basket
  37. 37. Conclusions  Using all endoscopic and ancillary techniques, stone clearance rate ~ 97%  Direct cholangioscopic stone removal could achieve near complete stone removal except in intra hepatic stones  CBDS management is multidisciplinary  Tailored on available resources and expertise

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  • AmitKayal3

    Nov. 24, 2016
  • fatematabak

    Apr. 15, 2017
  • LekshmiKRaju

    Jul. 28, 2017
  • AmalMukhtar3

    Nov. 25, 2017
  • natararu

    Jun. 4, 2018
  • debajyotichakraborty39

    Dec. 10, 2018
  • gouthami25

    Jun. 17, 2019
  • ThanNaingTun2

    Sep. 6, 2019
  • RashidAlam17

    May. 5, 2021

Cbd stones

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