A case presentation with discussion

1. Choledocholithiasis
Dr. Shirish Silwal
House Officer
Dept. of General Surgery & Urology
B & B Hospital Pvt. Ltd.

2. Case
• Mr NBR age 42 yr male admitted from SOPD
• Acute pain in epigastrium and RUQ for 5 days
• Pain is constant, dull , non radiating, aggravated by intake of
food a/w nausea , with yellowish discoloration of skin and
sclera.
• Passing dark coloured urine and clay coloured stools.
• No h/o fever, itching.
• No other co-morbidity and surgical history

3. • On examination
General condition >> fair
 Anaemia (-), Cyanosis (-), Oedema (-)
 Jaundice +++
Vitals stable
• Per Abdominal Finding
>>Tenderness and guarding present in right
upper quadrant.
Bowel sound (+)

4. INVESTIGATION
• HEMATOLOGY
• Liver Function Test
• BIOCHEMICAL TEST
WBC 5200 cu.mm
Neutrophils 82%
ESR 35mm/Hr
westergreen
Hb 15.2 gm
Platelets 60,000
BT 3min, CT 9min
PT 13.8, INR 0.99
Bilirubin T-14.8mg/dl
D- 10.4mg/dl
ALT/AST 207 / 207 IU/L
ALK P 600 IU/L
Urea/Cr 29/0.95
Na/K 133/3.3
Amylase/Lipase 117/218

5. • ULTRASONOGRAM
• HEMATOLOGY
Multiple choledocholithiasis
with obstructive dilatation of
CBD and IHBD. Mucocele of the
GB ? Impending acute
cholecystitis.
Hb 10.3
Platelets 58000, 88000, 22000
PT 13.4 ,INR 0.96
APTT 37sec

6. •PREOPERATIVE PERIOD
• Patient was managed conservatively up to 3rd
DOA.
• Patient was shifted to POW in 2nd DOA then to
ICU on same day.
• Antibiotics was stepped up from
CEFTRIAXONE AND METRONIDAZOLE>> MAGNEX
AND METRONIDAZOLE >>>MEROPENEM AND
METRONIDAZOLE.
• PRP 8 Pints was transfused then 2 packets
Concentrated platelets was transfused (PLTS
88000)
• VITALS: BP 130/80, PULSE 100, TEMP 98°F, SPO2
96% WITH 4L O2.

7. •INTRAOPERATIVE PERIOD
• Platelets 88000.
• OPEN CHOLECYSTECTOMY + ECBD + IOC was done
• Finding
Pre Gangrenous gall bladder containing multiple
calculi with sludge and infected bile.
Grossly dilated CBD and bilateral hepatic duct
containing multiple impacted calculi.
Moderate adhesions at the calot’s triangle . liver
normal
IOC- free flow of dye into bilateral hepatic ducts
and duodenum. No filling defect seen .

10. GALL BLADDER STONE CBD STONE

11. •POSTOPERATIVE FINDING
INVESTIGATION
• HEMATOLOGY
• BIOCHEMISTRY
• LIVER FUNCTION
Hb 8.2, 9.9,10.3,9.8 gm
Platelets-164000,152000
113000,120,000
WBC 15,400.
UREA 57,33,23
Cr O.80,0.63,0.62
Na/K+ 138/3.5
BILLIRUBIN T-5.7,10,9.8
D-4, 4.5,8
ALT-108,71,73
AST-114, 90,101
ALK P- 591,145,164

12. • 9th POD T-TUBE Clamp done
• 11th POD drain removed, suture all removed and
discharge.
• On 18th POD
• liver function test
Bilirubin T/D 3.7/2.6
ALT/AST 91/81
ALK P 245
• T-tube removed on 22nd POD

13. Discussion

14. •CHOLEDOCHOLITHIASIS
• Stone in common bile duct .
• 10 to 18% of patients with stones in the
gallbladder
• Incidence increases with age.
• About 20 to 25% of patients above the age of
60 with symptomatic gallstones have stones
in the common bile duct as well as in the
gallbladder.

15. TYPES OF STONE
• PRIMARY CBD STONE
A/W biliary stasis and infection
Brown pigmented
• SECONDARY CBD STONE
Stone migrate from gall bladder
cholesterol stones in 75%
black pigment stones in 25%

16. Clinical presentation
Jaundice ++
White coloured stools
Dark urine
Scratch marks in body
Yellowish discolouration of sclera, nail bed
Tender right upper quadrant,
Palpable gall bladder +/-

17. In severe condition
General appearance toxic
Jaundice +++
Vitals: hypotension, febrile, tachycardia
• Per abdominal finding
Tender right upper quadrant with guarding
Bowel sound sluggish or absent
Charcot’s triad of cholangitis
right upper quadrant pain, jaundice, and fever.

18. • Common bile duct stones are covered by a bacterial biofilm
of adherent quiescent bacteria residing in a hermetic
environment.
• When stones cause obstruction of the ducts, cytokines
released by epithelial cells activate these bacteria to the
virulent forms.
• Sepsis is much less likely to occur in the context of
malignant obstruction without choledocholithiasis.
Maingot's Abdominal Operations

19. Courvoisier's law
In his book “Casuistisch-statistische Beiträge zur
Pathologie und Chirurgie der Gallenwege”
The pathology and surgery of the gallbladder” published in
Liepzig in 1890, Ludwig Courvoisier - a swiss surgeon stated
that “with obstruction of the common duct by a stone,
dilatation is rare. The organ is usually well shrunken. With
obstruction from other kinds, on the contrary, distension is
the rule. Shrinking occurs in only one twelfth of cases.”

20. • If gallbladder is palpable in a jaundiced patient, it is
unlikely to be due to gallstones, because stones would have
given rise to chronic inflammation and subsequently
fibrosis of gallbladder therefore, rendering it incapable of
dilatation. Conversely, the causes other than stone
(principally tumours), would result in the distension of
gallbladder, felt on abdominal palpation.

21. Investigation
• Elevation of serum bilirubin, alkaline phosphatase, and
transaminases are commonly seen in patients with bile
duct stones.
• Ultrasonography
• Magnetic resonance cholangiography (MRC)
• Endoscopic cholangiography
Schwartz's Principles of Surgery

22. Management
• Primary management
High glucose diet
Protein restriction
IV Broad spectrum antibiotics
Vitamin K
Lactulose
Correction of metabolic and coagulation abnormality

23. Definite Management
• If an endoscopic cholangiogram reveals stones, sphincterotomy
and ductal clearance of the stones is appropriate, followed by a
laparoscopic cholecystectomy.
• Open common bile duct exploration is an option if the
endoscopic method has already been tried or is, for some
reason, not feasible. If a choledochotomy is performed, a T tube
is left in place.
• Stones impacted in the ampulla may be difficult for both
endoscopic ductal clearance as well as common bile duct
exploration (open or laparoscopic). In these cases the common
bile duct is usually quite dilated (about 2 cm in diameter). A
choledochoduodenostomy or a Roux-en-Y
choledochojejunostomy may be the best option under this
circumstance.
Schwartz's Principles of Surgery

24. Surgical versus endoscopic treatment of bile duct stones
• 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. There is no significant difference in the mortality, morbidity, retained
stones, and failure rates between the single-stage laparoscopic bile duct
clearance and two-stage endoscopic management. More randomised clinical
trials without risks of systematic and random errors are necessary to confirm
these findings.
Cochrane Database Syst Rev. 2013 Sep 3;9:CD003327. doi: 10.1002/14651858.CD003327.pub3.

25. Primary closure
• Primary closure of the CBD after exploration can be done
only if certain criteria such as the following are satisfied:
• Patent ampulla of Vater
• Complete removal of all intraductal calculi
• Absence of pancreatic pathology
• Meticulous suture of the duct
Indian J Surg (July–August 2012) 74(4):323–324

26. World Journal of Surgery
January 2012, Volume 36, Issue 1, pp 164-170
Primary Closure Following Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Cholangiography and Choledochoscopy
Background
Laparoscopic common bile duct exploration (LCBDE) has become one of the main options for treating choledocholithiasis associated with cholelithiasis. Our
objective was to assess the short-term outcomes of patients undergoing laparoscopic primary closure of the common bile duct (CBD) compared with
laparoscopic choledochotomy plus T-tube drainage.
Methods
We retrospectively studied 137 patients undergoing primary closure following LCBDE (group A) compared with 102 cases with laparoscopic
choledochotomy plus T-tube drainage (group B) between January 2007 and January 2010. Intraoperative cholangiography (IOC) and choledochoscopy were
performed in all patients.
Results
Three patients in group A (2.2%) were converted to open surgery and two (2.0%) in group B because of serious adherence. According to routine IOC,
unexpected CBD stones were found in 16 cases (6.8%). The duration of the operation in group A was shorter than in group B (92.4 ± 15.2 vs.
125.7± 32.6 min, P < 0.05), as was length of postoperative stay (3.1± 2.4 vs. 5.7± 4.3 days, P < 0.05). Postoperative bile leakage occurred in six patients
(4.5%) in group A and four cases (4.0%) in group B; all of the patients recovered after simple drainage without reoperation. Bile peritonitis was seen in one
case after T-tube removal. The median follow-up was 26 months. There were no recurrences.
Conclusions
Laparoscopic primary closure of the CBD is safe and successful for the management of CBD stones. Application
of IOC and choledochoscopy to ensure clearance of the CBD and careful suturing are essential for primary
closure.

27. T-tube drainage versus primary closure after open
commonbile duct exploration
T-tube drainage appeared to result in significantly longer operating time and hospital stay
compared with primary closure without any apparent evidence of benefit on clinically
important outcomes after open common bile duct exploration. Based on the currently
available evidence, there is no justification for the routine use of T-tube drainage after open
common bile duct exploration in patients with common bile duct stones. T-tube drainage
should not be used outside well designed randomised clinical trials. More randomised trials
comparing the effects of T-tube drainage versus primary closure after open common bile
duct exploration may be needed. Such trials should be conducted with low risk of bias and
assessing the long-term beneficial and harmful effects of T-tube drainage, including long-
term complications such as bile stricture and recurrence of common bile duct stones.
T-tube drainage versus primary closure after open common bile duct exploration (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons,
Ltd.

28. INDICATION OF CHOLEDOCHODUODENOSTOMY
• Dilated common duct > 15mm with stones
• Multiple common bile duct stones
• Intra hepatic calculi
• Primary common bile duct stones
• Residual / Recurrent stones
• Stone impacted in the ampulla of Vater
• Side to side CDD is an easy, effective and definitive method
of decompression, especially when there are multiple
stones in a dilated CBD
Kathmandu University Medical Journal (2003) Vol. 2, No. 3, Issue7, 193 - 197

29. N Am J Med Sci. 2013 Apr;5(4):288-92. doi: 10.4103/1947-2714.110438.
Open Choldecho-Enterostomy for Common Bile Duct Stones: Is it Out of Date in Laparo-Endoscopic Era?
Abdelmajid K, Houssem H, Rafik G, Jarrar MS, Fehmi H.
Source
Department of General Surgery, Professor Rached Letaief at Farhat Hached Hospital, Sousse, Tunisia.
Abstract
BACKGROUND:
Nowadays, biliary-enteric drainage (BED) is regarded as a last resort or obsolete therapeutic method for common bile duct stone (CBDS) not only because of
advances in minimally invasive therapeutic modalities but also due to fears of higher morbidity, cholangitis, and "sump" syndrome.
AIM:
The present study aimed at evaluating the outcome of this procedure for choledocholithiasis.
MATERIALS AND METHODS:
It is a retrospective review of 51 patients who underwent open choledochoenterostomy for CBDS between January 2005 and December 2009.
RESULTS:
About 40 women (78%) and 11 men underwent open BED (mean age 72 years). Indications were elderly patients (90%), multiple stones (54.9%) and
unextractable calculi (15.4%). We performed 49 (96%) side to side choledochoduodenostomies, one end to side choledochoduodenostomy (CDS) and one
end to side hepaticojejunostomy. The mortality rate was 3.9%. Overall morbidity was 12% with no biliary leakage. With a decline of 1-6 years, neither sump
syndrome nor cholangiocarcinoma occurred.
Conclusion
Side-to-side CDS is a safe and highly effective therapeutic measure, even when performed on ducts less than 15 mm wide,
provided a few technical requirements are respected. Patients experiencing relapsing cholangitis after Biliary enteric
drainage should be closely monitored for the late development of biliary tract malignancies .
N Am J Med Sci. 2013 Apr;5(4):288-92.

31. INDICATION OF HEPATOJEJUNOSTOMY
• frequently with the advent of laparoscopic
cholecystectomy and its higher rate of bile duct injuries.
• biliary fibrosis produced by chronic pancreatitis
• penetrating trauma of the porta hepatis
• previous bilioenteric operations with subsequent stricture
formation
• choledochal cyst resections
• Iatrogenic biliary trauma (gastrectomy, pancreatic and
hepatic resections, portal decompressive procedures, and
liver transplantation)

32. • Malignant conditions
cholangiocarcinomas and carcinomas of the gallbladder
infiltrating the common bile duct (CBD) or hepatic ducts may
also be indications for performing HJ as the final step of the
resective procedure or as a palliative attempt to relieve
jaundice.
From the Department of Surgery, Mayo Clinic, Rochester, MN.

33. Conclusion
• Choledocholithiasis occurs in about 10 to 18% of patients with
cholelithiasis .
• Although USG is not the best but it is the commonest first line
investigation.
• Endoscopic cholangiography is the gold standard for diagnosing
common bile duct stones
• Surgical Procedure depends upon expertise and experienced of
surgeon, patient condition and facilities available.
• Minimal invasive procedure encouraged for less postoperative
co-morbidity and mortality .

34. Thank you