ERCP is essential to diagnose and treat obstructive surgical jaundice but surgery is mandatory in some cases

1. Common Bile Duct Stone
ERCP Vs Surgery
DR. Sameh Tolba, M.D.
Lecturer of general &Laparoscopic Surgery
Faculty of Medicine-Suez Canal University

2. • Stones in the common bile duct most commonly result from the
passage of gallstones through the cystic duct into the common bile
duct. Less frequently, they may originate in the common bile duct
itself. Stones in the common bile duct can cause biliary obstruction,
cholangitis, pancreatitis, or secondary biliary cirrhosis in patients
who have had the stones for a long time. More than 1 in 10 patients
(10%–18%) undergoing cholecystectomy for gallstones have
concomitant common bile duct stones, and up to 3.8% have
symptoms related to common bile duct stones during the first year
after cholecystectomy.

3. • The management of patients with gallstone disease
suspected of having stones in the common bile duct
has three aims:
-To evaluate the probability of stones in the
common bile duct,
-To treat these stones when present,
-And to treat the stones in the gallbladder.

4. When should common bile duct stones be suspected?
• Symptoms and signs suggestive of common bile duct stones can
occur in people with intact gallbladders as well as those who have
had a cholecystectomy. The clinical presentation includes
abdominal pain, jaundice, nausea, vomiting, fever, cholangitis,
pancreatitis, and elevated levels of bilirubin or liver enzymes.
Patients may also require investigation following an incidental
finding of a dilated common bile duct or a stone in the common bile
duct, or both.
• Because direct cholangiography is often invasive, involving the
injection of a contrast agent directly into the common bile duct, many
predictive clinical models for common bile duct stones have been
proposed.

6. • The evaluation of common bile duct stones in patients
with gallstone disease involves stratifying their
probability of having a stone in the common bile duct to:
low (< 10%), intermediate (10%–50%) or high (> 50%).

7. • High risk (>50%) of choledocholithiasis:
– clinical jaundice, cholangitis,
– CBD dilation or choledocholithiasis on ultrasound
– Tbili > 3 mg/dL correlates to 50-70% of CBD stone
• Moderate risk (10-50%):
– h/o pancreatitis, jaundice correlates to CBD stone in 15%
– elevated preop bili and AP,
– multiple small gallstones on U/S
• Low risk (<5%):
– large gallstones on U/S
– no h/o jaundice or pancreatitis,
– normal LFTs

8. Which imaging modalities are useful?
• Many imaging modalities are available for investigating suspected
stones in the common bile duct. These include older techniques
such as intravenous cholangiography and endoscopic retrograde
cholangiopancreatography (ERCP) and newer techniques such as
magnetic resonance cholangiopancreatography and endoscopic
ultrasonography .
• In most instances, preoperative diagnosis of stones in the common
bile duct involves a context-sensitive approach based on the pre-
procedural probability of the stones rather than the routine use of
any of these modalities. Variations exist in the availability and
expertise of these techniques.

10. Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP)
– Advantage
• Detects choledocholithiasis, neoplasms, strictures, biliary
dilations
• Sensitivity of 85-100%, specificity of 92-100% of
choledocholithiasis
• Minimally invasive- avoid invasive procedure in 50% of
patients
– Disadvantage:
• cannot sample bile, test cytology, remove stone
• Contraindications: pacemaker, implants, prosthetic valves
– Indications
• If cholangitis not severe, and risk of ERCP high, MRCP
useful
• If Charcot’s triad present, therapeutic ERCP with drainage
should not be delayed.
Endoscopic retrograde cholangiopancreatography
(ERCP)
-Gold standard for diagnosis of CBD stones, pancreatitis,
tumors, sphincter of Oddi dysfunction
-Advantage
•Therapeutic option when CBD stone identified
•Stone retrieval and sphincterotomy
-Disadvantage
•Complications: pancreatitis, cholangitis, perforation of
duodenum or bile duct, bleeding
•Diagnostic ERCP complication rate 1.38% , mortality
rate 0.21%

11. MRCP
• purely diagnostic .
• rapid, accurate and non-
invasive
• Safe :
no contrast material
administration
no radiation.
• alternative to diagnostic
ERCP.
• MRCP avoids the
complications of ERCP

12. • Normal MRCP. good delineation of normal
caliber pancreatic and bile ducts. Fluid in
stomach and duodenum also demonstrated.

13. • MRCP. Large common hepatic duct stone
(asterisk) within dilated bile ducts. Note
multiple gallstones

14. Elective management of suspected stones in the common bile duct before laparoscopic
cholecystectomy. *If endoscopic retrograde cholangiopancreatography (ERCP) fails, open
cholecystectomy with exploration of common bile duct should be considered. †When the r...
Majid A. Almadi et al. CMAJ 2012;184:884-892
©2012 by Canadian Medical Association

15. What treatment options are available?
• Once popular, open surgical techniques have been superseded by
endoscopic techniques. The most common treatment modality is
ERCP, with duct cannulation and clearance rates reaching 98% in
expert hands. Intraoperative ERCP at the time of laparoscopic
cholecystectomy (also called “laparoendoscopic rendezvous”) is
practised in some centres. It may have advantages, but it presents
substantial logistical challenges. It involves the placement of a wire
through the cystic duct to the ampulla at the time of laparoscopic
cholecystectomy to ensure successful ERCP cannulation.

16. • Open surgical exploration of the common bile duct was historically
combined with intraoperative cholangiography at open
cholecystectomy to diagnose and treat common bile duct stones. In
the start of the era of laparoscopic cholecystectomy, surgical options
have been limited mainly to intraoperative cholangiography and
occasional transcystic stone removal.
• The surgical removal of common bile duct stones, whether open or
laparoscopic, has become a seldom-performed operation, usually
reserved for patients in whom ERCP has failed. Failure rates with
conventional ERCP for the removal of large stones in the common
bile duct can reach 20% Laparoscopic exploration of the common
bile duct should be considered in patients with larger stones, but it is
practised by few groups.

17. • Many trials showed that laparoscopic treatment of CBD stones is
safe.(Paganini etal,1998, Tranter etal,2002, Nassar etal,2015) CBD
stones can be removed via the cystic duct or through
choledochotomy.
• Smadja etal, 2006, stated that, In patients fit for surgery, in most
cases, there is no place for preoperative investigations to ascertain
the presence of stones in the CBD. IOC is indicated in selected
patients. Selection of patients is based on simple preoperative
criteria. Finally, postoperative ES should be performed in patients
with retained stone or when laparoscopic CBD stones extraction has
failed.

18. • The transcystic approach is indicated in case of small stones in a
limited number with a large cystic duct with a modal implantation. It
is worth mentioning that in the transcystic duct approach, stones
smaller than 3 to 4 mm in size can often be flushed through the
ampulla into the duodenum, which is facilitated by relaxation of the
sphincter of Oddi using intravenous glucagon. When this method
fails, a Dormia basket can be passed through the cystic duct and
into the CBD to extract stones. If attempts at transcystic Dormia
basket extraction fail, a flexible endoscope should be inserted to
remove the stones under direct vision.

20. Thank You