CBDSs are one of the medical conditions leading to surgical intervention. They may occur in 3%–14.7% of all patients for whom cholecystectomies are preformed. When patients present with CBD, the one important question that should be answered: what is the best modality of treatment under the giving conditions? There are competing technologies and approaches for diagnosing CBDS with regard to diagnostic performance characteristics, technical success, safety, and cost effectiveness. Management of CBDS usually requires two separate teams: the gastroenterologist and the surgical team. One of the main factors in the management is initially the detection of CBDS, before, during, or after cholecystectomy. The main options for treatment are pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST), laparoscopic or open surgical bile duct clearance. There are other options for the treat- ment of CBDS such as electrohydraulic lithotripsy (EHL), extracorporeal shockwave lithotripsy (ESWL), dissolving solutions, and laser lithotripsy. It is unlikely that one option will be appropriate for all clinical circumstances in all centers. Variables such as disease status, patient demographics, availability of endoscopic, radiological and surgical expertise, and healthcare economics will all have significant influence on practice

1. CBD Stones (Choledocholithiasis)
Present Technical Challenges
Prof. Dr Sreejoy Patnaik
Consultant GI Surgeon, Bariatric Surgery
Shanti Memorial Hospital, Cuttack
Governing Council Member ASI – 2016-2021
Organising Secretary, ASICON -2019,Bhubaneswar
Organising Secretary, IAGES -2019,Bhubaneswar

2. Introduction:
Choledocholithiasis refers to the presence of gallstones within the CBD.
Incidence - 15–20% of patients with cholelithiasis
Primary stones that originate in the bile duct.
Secondary stones that have descended from the GB .
In most cases it’s the passage of gallstones from GB into the CBD.
In the primary stones, bilirubin is dominant component (associated with biliary stasis and infection).
In secondary stones, cholesterol is dominant component.
Primary CBDS are less common & typically occurs in the setting of bile stasis (eg, patients with cystic fibrosis).
Biliary tract diffusely affected - both extrahepatic and intrahepatic biliary stones.

4. Uncomplicated choledocholithiasis
Symptoms — Most patients are symptomatic but without any complications.
Literature describes the prevalence of asymptomatic CBDS - 5.2% and 12% .
• RUQ or epigastric pain,(typical biliary colic) nausea, and vomiting.
• The pain is often more prolonged ,typically resolves within six hours.
• Typically afebrile and have a normal CBC & pancreatic enzyme levels.
• Diagnosed by abnormal LFT, abnormalities seen on imaging studies, or when an IOC obtained during
Physical examination —
RHQ or epigastric tenderness.
Jaundice - +++
A palpable gallbladder
Clinical Manifestations:

5. Complicated choledocholithiasis —
The two major complications associated with choledocholithiasis are Acute Pancreatitis (AP)
and Acute Cholangitis ( AC).
Acute Pancreatitis - typically present with nausea, vomiting, elevations in serum amylase
and lipase.
Acute cholangitis - present with Charcot's triad (fever, right upper quadrant pain, and
jaundice) and leukocytosis.
In severe cases, bacteremia and sepsis may lead to hypotension and altered mental status
(Reynolds' pentad).
Long-standing biliary obstruction may progress to cirrhosis,(secondary biliary cirrhosis)
Clinical Manifestations:

6. Retained CBDS : The Problem
1-4% found to have retained CBD stones after Cholecystectomy
5-10% found to have retained CBD stones after CBD exploration
20% of the patients who underwent reoperations for residual or recurrent stones will develop
choledocholithiasis again
5.2%-12% retained stones are asymptomatic
Surgeon – Frustration, Culpable, loss of rapport
Expenditure
Risk of complications
Robert M Girard, Annals of Surgery 2016

7. Describing the CBD stones
Primary stones (brown pigment stones) Mud - like, Non-laminated.
Secondary stones (usually cholesterol) Laminated stones, faceted.
Residual stones, which are missed at the time of cholecystectomy (evident < 3 yr later).
Recurrent stones, which develop in the ducts > 3 yr after surgery.

8. Recurrent CBD stone - Causes
Saharia PC et al Ann Surg 1977
Idiopathic Recurrent cholangitis
 Primary CBD stones
Secondary to Biliary stasis
Biliary strictures, Bilio-enteric anastomotic stenosis / stricture
Stone formation over foreign body nidus – suture / clip / stent / worm
Missed Choledochal cyst

9. Retained CBD stones
Patients who underwent Cholecystectomy and Choledocholithitomy
Again noted to have CBD stone
Because
Stone was either Missed - “Retained CBD stone”
Or
Formed Again “Recurrent CBD stone”
Arch Surg. 1964;88(3):486-489

10. Retained or Missed CBD stones - Causes
 Inadequate / Incorrect pre-operative CBD assessment
 Spontaneous stone migration from GB in the interval between pre-op evaluation and surgery
 Stone migration during operative manipulation
 Technical error / misjudgment during CBD clearance
 Inadequate Completion check
 Interval between ERC stone clearance and Lap Cholecystectomy
 Stones in a long cystic duct
 Intrahepatic stones
 Residual Gallbladder with stones

11. Presentation of CBD stones
 Abnormal LFT
 Biliary Pain
 Obstructive Jaundice
 Fever
 Pruritus
 Cholangitis
 Pancreatitis
 Many patients present in Emergency

12. Presentation of CBD stones

13. Lab Tests
Early in the course of biliary obstruction:
Serum alanine aminotransferase (ALT) and aspartate aminotransferase (AST) concentrations get typically elevated
Later in the course of obstruction:
Enzymes typically elevates in a cholestatic pattern with increases in
– Serum bilirubin,
– Alkaline phosphatase, and
– Gamma-glutamyl transpeptidase (GGT)
– Serum ALT and AST.
An elevation in serum bilirubin had a sensitivity of 69% and a specificity of 88% diagnosing CBDS.
For elevations in serum alkaline phosphatase, the values were 57 and 86%, respectively.
Elevated serum GGT, ALP , and bilirubin levels were independent predictors of CBDS on multivariable analysis
(odds ratios of 3.2, 2.0, and 1.4, respectively).

14. Imaging Studies
1.Transabdominal ultrasound
2. EUS (Endoscopic ultrasound)
3.Conventional computed Tomography ( CT)
4. MRCP (Magnetic resonance cholangiopancreatography)
5. ERCP (endoscopic retrograde cholangiopancreatography)
6.Intraoperative Cholangiography (IOC)
7.Intra Ductal Ultrasonography (IDUS)
8.Per Cutaneous Transhepatic Cholangiography ( PTC)

15. Transabdominal ultrasound
The initial imaging study of choice in suspected CBDS.
Evaluates for cholelithiasis, choledocholithiasis, and CBD dilatation.
It is readily available, non-invasive, permits bedside evaluation, low-cost .
The sensitivity ranges from 20 to 90% with a specificity of 91%.
Poor sensitivity for stones in the distal CBD (obscured by bowel gas) .
A dilated CBD is suggestive of, but not specific for, choledocholithiasis
A cut off of 6 mm is often used to classify a duct as being dilated.
The probability of a stone in the CBD increases with increasing CBD diameter:
 0 to 4 mm: 3.9 percent
 4.1 to 6 mm: 9.4 percent
 6.1 to 8 mm: 28 percent
 8.1 to 10 mm: 32 percent
 >10 mm: 50 percent

16. EUS
It involves the convergence of endoscopy and US probe.
US Probe at tip allows detailed views of GI tract wall and adjacent structures.
Sensitivity of EUS varies from 95%, while specificity is between 95–98% .
Its sensitivity is comparable to the diagnostic ERCP.
It is a non invasive, with excellent overall sensitivity and specificity for diagnosing CBDS.
Highly dependent & expert hands.
Biliary sludge can be detected but generally not by MRCP.
Should be considered in patients in whom the suspicion for CBDS with negative MRCP.

17. EUS

18. Abdominal computed tomography (CT)
It has a sensitivity of 87% and a specificity of 97% for the diagnosis of CBD
stones .
Kondo et al. showed that CT scanning was equivalent to MRCP.
Use of IV contrast media combined with a helical cholangiography protocol,
increases the sensitivity and specificity.

19. MRCP
MRCP is an accurate , non invasive diagnostic modality for investigating the biliary ducts.
MRCP has an excellent overall sensitivity of 95% and a specificity of 97% for demonstrating CBDS.
A review of 13 studies found that MRCP had a median sensitivity of 93 percent and a median specificity of 94 percent
The sensitivity of MRCP may be lower for small stones <6 mm and sludge.
Major disadvantages, as compared to ERCP, are:
 unit availability,
 inability to evaluate patients with pacemakers or ferromagnetic implants.
 potential for claustrophobia,
 lower spatial resolution,

20. MRCP

21. MRCP – 3 D – 360 deg. MRCP – multiple stones

22. Endoscopic retrograde cholangiopancreatography (ERCP)
Traditionally was used both as a diagnostic and therapeutic procedure in patients with suspected CBDS.
The sensitivity is estimated to be 80 to 93%, with a specificity of 99 to 100%.
Is invasive, requires technical expertise, and is associated with complications such as pancreatitis,
bleeding, and perforation.
Reserved for those with high risk for having a CBDS , with evidence of cholangitis & stone
demonstrated by other imaging modalities.

23. Endoscopic retrograde cholangiopancreatography (ERCP)

24. Intraoperative cholangiography (IOC)
It has an estimated sensitivity of 59 - 100% & specificity of 93 to 100%.
Highly operator-dependent and is not routinely performed by many surgeons.
Done under Fluoroscopic control.
Technically unfeasible in patients with a severely inflamed GB.
Disadvantages:
1.Inability to cannulate the cystic duct.
2.Leakage of contrast fluid during the injection, air bubbles mimicking stone.
3.Failure to fill the biliary tree because of too rapid contrast injection into the
duodenum, and spasm of the sphincter of Oddi.
4.Lengthening of the operative time by approximately 15 minutes.

25. Intraoperative cholangiography (IOC)

26. Intraductal ultrasonography (IDUS)
Intraop. approach for detecting CBDS
During lap., an US probe is inserted into the peritoneal cavity though a 10-mm trocar and is used to scan the bile ducts.
The reported sensitivity and specificity are over 90%.
Should routinely be used intraop. + selective IOC for accurate diagnosis of CBDS.
Reduces the need for IOC.
Excellent method for detecting residual small stones in the CBD after endoscopic lithotripsy..
Especially recommended in pts with dilated bile ducts with suspected small bile duct
stones when ERCP is not diagnostic .

27. Percutaneous transhepatic cholangiography(PTC)
Indications:
1. Is typically performed in patients who are not fit for ERCP.
2. Failed ERCP.
3. Distal obstructing CBDS
4. Surgically altered anatomy preventing endoscopic access to the biliary tree.(previous gastric surgery).
5. Extensive Intrahepatic stones.
6. Cholangiohepatitis
7. Invasive procedure / therapeutic procedure.

28. Percutaneous transhepatic cholangiography(PTC)

29. Treatment algorithm for choledocholithiasis

30. Treatment Modalities
Patients with CBD stones and retained ones must be offered stone extraction
1. Endoscopic clearance –ERCP / Spyglass cholangioscopy
2. Surgery – Laparoscopy / Open
3. Choledoco – Enterostomy ( Diversion)
4. Non-surgical Mechanical extraction Via T-Tube
5. Per-cutaneous radiological stone extraction
6. Rendezvous – Combination techniques (Endo- lap)
7. Endoscopic ultrasound (EUS)-directed transgastric ERCP (EDGE)
8. Electrohydraulic Lithotripsy
9. ESWL – Extra corporeal shockwave lithotripsy.
10. Laser Lithotripsy
11. Chemical dissolution
Updated guidelines on the management of CBD stones. Earl Willaims et al, Gut 2017

31. Choosing the Modality
1. General condition
2. Bilio-digestive Anatomy
3. Nature of Previous Surgery
4. Previous interventions / complications
5. Stone size, number, location
6. Associated Pathology / Comorbidities
7. Expertise and availability

32. ERCP
Mainstay
ERCP is highly sensitive and specific for choledocholithiasis
Success rate of approximately 87–97% for ductal clearance with proper expertise.
Upto 25% of patients require two or more sittings of treatment
Morbidity 6%, mortality 0.2 %
Two groups of interventions:
(1) pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST) in a two-staged procedure,
(2) surgical bile duct clearance and cholecystectomy as one- stage procedure.
Complications -include bleeding, duodenal perforation, cholangitis, pancreatitis, and bile duct injury .
Not possible in 3% to 10% of all patients .

33. Video on Lapchole + ERCP

34. Lap CBD Exploration
Depends on several factors including:
-surgical expertise.
-adequate equipment.
-biliary anatomy.
-number and size of CBD stones.
Successful stone clearance rates ranging from 85% to 95%.
Morbidity rate of 4%–16% and a mortality rate of around 0%–2%.
Complications:
-CBD laceration.
-stricture formation.
-bile leak.
Significantly shorter hospital stay and lower hospital costs as compared with ERCP/EST.
Tai et al. reported that the clearance rate was 100%, and no recurrence was discovered during a mean followup period of 16 months.

35. There are two primary methods for LCBDE:
Trans-cystic (via the cystic duct) and
Trans-ductal (via choledochotomy).
Stones detected at the time of LC , the best treatment is a trans-cystic approach during
the same operation.
Trans-cystic approach is generally used for small stones in a small bile duct.
Trans-ductal approach is preferred for:
A. large occluding stones in a large duct,
B. intrahepatic stones,
C. tortuous cystic duct.
Lap CBD Exploration

36. Contra-indications
1. Stone diameter > 6mm
2. Cystic duct diameter < 4mm
3. Intra hepatic stones
4. Cystic duct entrance - posterior or distal to CBD stones
Advantages
1. T-tube is eliminated
2. Risk of CBD stricture post. choledochotomy is eliminated

37. LCBDE-Trans-Cystic Approach.

38. LCBDE-Trans-Ductal Approach.
Indications :
1. Failed laparoscopic transcystic exploration or preoperative ERCP stone extraction
2. Narrow entrance & course of CD ( spiral,very low, post.)
3. Valves in the CD.
4. Dilated CBD > 1 cm
5. Large stones > 10 mm or impacted, requiring lithotripsy.
6. Multiple stones
7. Intra-hepatic stones.
8. Suturing ability -good

39. LCBDE-Trans-Ductal Approach-
Contra-indications:
1. CBD diameter less than 6mm
2. Poor laparoscopic suturing ability

40. Lap CBDE :CBDE +T-tube ; C-Duodenostomy – Stone over stent

41. Approaches to Recurrent CBDS?
Pose a challenge in the Mx of CBDS.
RISK FACTORS INCLUDE:
Multiple large stones
Primary / Recurrent stones
Distal biliary stricture, tumor, angulation of CBD.
Markedly dilated ducts >13mm.
Hepatolithiasis ( factors leading to biliary stasis – ampullary diverticula.)
SURGICAL OPTIONS:
1.Repeat ERCP interventions.
2..Surgical Internal Biliary Drainage (Lap or Open)
Choledochoduodenostomy
Roux-en Y Hepaticojejunostomy
3.Transduodenal Sphincteroplasty

42. BILIO-ENTERIC BYPASS
Indications:
Multiple CBD stones
Recurrent choledocholithiasis
Unsuccessful sphincterotomy
Impacted large CBD stones
Markedly dilated CBD
Choices:
Choledochoduodenostomy
Transduodenal sphincteroplasty/ERCP + ST
Hepatico -jejunostomy

43. Lap.Choledochoduodenostomy

44. Rendezvous Technique
INDICATIONS:
Unsuccessful cannulation of biliary tree during ERCP.
1.Single staged procedure: Lap with Intra-op ERCP
2. Staged procedure :
Percutaneous trans-hepatic (PTBD) guidewire is fed
retrogradely through the papilla into the duodenum
followed by ERCP. (Radiologist)
Team support and Logistics
Complications: rates 5-30% , perforation, pancreatitis.

45. Failed ERCP or surgery?
Mechanical lithotripsy: with a reinforced basket with a spiral sheath can be successful in
over 80% of cases .
Scope choledochoscopes: (e.g., Spyglass) that are now available that can administer
intracorporeal electrohydraulic or laser lithotripsy.
Laser lithotripsy: involves laser light of a high-power density, traditionally Holmium or
Yttrium-aluminum-garnet (YAG) laser.
ESWL: involves shock waves that are delivered in brief pulses directly at the stone by the
probe, which is optimally located approximately 1–2 mm from the stone.
(Renal Stones)

46. Spyglass Cholangioscopy
The SpyGlass™ DS System ( SPYSCOPE)
 Direct visualization of the BD and PD.
 Evaluates suspected benign and malignant
conditions
 Mx of difficult stones,
 Bx from masses
 Stricture Mx.

47. Electrohydraulic lithotripsy

48. Non-endoscopic, Non-surgical options for achieving biliary decompression.
Percutaneous transhepatic biliary drainage (PTBD) – malignancy
- the intrahepatic bile ducts need to be dilated and if other methods of stone
extraction have failed.
 Temporary External Drain,
 Internal Drain
 Internal stent for biliary drainage.
Indications: setting of sepsis secondary to acute cholangitis.
Creation of a transhepatic fistula - procedures via the drain ( fistula) tract –
 basket retrieval,
 electrohydraulic lithotripsy
 laser lithotripsy
 rendez-vous procedure

49. Techniques with altered gastric or duodenal anatomy?
CBDS with altered anatomy, (Billroth II or Roux-en-Y gastric bypass,) pose significant
challenges for access to the biliary tree by the conventional transoral manner.
Balloon-assisted ERCP or endo USG trans gastric ERCP (EDGE procedure) can be
attempted but both require advanced endoscopic expertise.
The excluded stomach is located by ENDO-USG from the gastric pouch or afferent limb
and accessed to deploy a lumen-apposing metal stent into the excluded gastric remnant to
allow a ERCP scope through the fistula to access the biliary tree.
ENDO + USG – Gastric pouch.
LAP + ENDO – Gastric remnant.

50. ERCP THROUGH GASTRIC REMNANT

51. Chemical dissolution Agents:
Oral ursodeoxycholic acid has been documented to have a potential role in facilitating stone
clearance by reducing the size of CBDS.
Direct infusions of the common bile duct through a T-tube / PTBD
 Heparin
 Sodium cholate
 Mono-octanoin
 Clofibrate
Dissolution / Flushing
Multiple sessions
Variable success
Complications:
Fever, Cholangitis, Raised enzymes, Pancreatitis

52. Identifying the Challenges
 Biliary stricture
 Duodenal Diverticula
 Internal Biliary fistulae
 Previous ERC related complication
 Acute Pancreatitis
 Portal Biliopathy
 CLD / Cirrhosis / PHTN
 Bile leak
 Impacted stones
 Intra-hepatic stones
 Choledochal cyst
 Residual Gallbladder
 Underlying Malignancy
 Previous G.I surgery / Bariatric Surgery

53. Conclusions
CBDS is a commonly encountered diagnosis for most of the general surgeons.
Mx depends on-
 decision making based on clinical presentation and investigations,
 the timing of presentation in relation to Sx.
 availability of technology
 expertise of the surgeons, endoscopists and interventional radiologists.
Surgeon must be familiar with all possible options at their disposal.

54. Take home Message
Today, management of CBDS is quite complicated.
USG and MRCP are routine diagnostic modalities in most centres.
LCBDE (trans-cystic or trans-ductal) is a standard method with a high efficacy, low morbidity and mortality in
most centres.
Pre- or postoperative ERCP/EST can be use as an alternative method.
ERCP should be performed as a 1STstep and in the event of failure, LCBDE can be performed.
Open approach always remains as a final option when other modalities fail.
EHL, ESWL, laser lithotripsy, and dissolving solutions have special indications and more clinical trials in this
area must be performed.

55. THANK YOU