The document discusses various approaches for managing common bile duct (CBD) stones, including:
- Preoperative identification using blood tests, ultrasound, ERCP, MRCP, which have varying sensitivity and specificity
- Intraoperative options like cholangiography, laparoscopic ultrasound, and indocyanine green injection
- Postoperative ERCP can be used for diagnostic and therapeutic purposes but has risks of pancreatitis and cholangitis
- The optimal management strategy depends on individual patient risk factors and circumstances.
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
The diagnosis and management of common bile duct stones has evolved considerably in recent years. New endoscopic, radiologic and surgical techniques now provide doctors with a range of options. We present an evidence based approach which incorporates the latest technology and techniques to optimize outcomes for patients.
Common Bile Duct Stones: A Therapeutic ChallengeKETAN VAGHOLKAR
Common bile duct stones (CBD) continue to pose the greatest challenge to the general surgeon. The morbidity associated with CBD
stones is extremely high. Management of CBD calculi requires a systematic approach to keep the morbidity and mortality associated with this
condition to a bare minimum. With the advent of advances in interventional endoscopy to manage CBD calculi, selecting the best approach is
the biggest challenge. The article discusses the complexities underlying the pathophysiology and management of CBD calculi
We review the most important articles above the differents Precut techiques: Fistulotomy, Papillotomy and Transpancreatic Sphincterotomy. The techique is safe and effective. And a brief comment about my experience in Fistulotomy, "No Post ERCP Pancreatitis because No touch the papilllary orifice"
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
EUS Guided Interventions for Pancreatobiliary TumoursJarrod Lee
Endoscopic Ultrasound (EUS) has advanced rapidly in recent years, and has evolved from a primarily diagnostic tool, to one that has an increasing role in interventions. We review the latest roles of EUS guided interventions for pancreas and bile duct tumours.
The lecture was the plenary lecture at the Philippines National Endoscopy Conference 2014
Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.
Common Bile Duct Stones: A Therapeutic ChallengeKETAN VAGHOLKAR
Common bile duct stones (CBD) continue to pose the greatest challenge to the general surgeon. The morbidity associated with CBD
stones is extremely high. Management of CBD calculi requires a systematic approach to keep the morbidity and mortality associated with this
condition to a bare minimum. With the advent of advances in interventional endoscopy to manage CBD calculi, selecting the best approach is
the biggest challenge. The article discusses the complexities underlying the pathophysiology and management of CBD calculi
We review the most important articles above the differents Precut techiques: Fistulotomy, Papillotomy and Transpancreatic Sphincterotomy. The techique is safe and effective. And a brief comment about my experience in Fistulotomy, "No Post ERCP Pancreatitis because No touch the papilllary orifice"
Safe Laparoscopic Cholecystectomy Techniques that are discussed here are based on current literature and Evidence Based Medicine guidelines and reviews.
The incidence of biliary injury after laparoscopic cholecystectomy (LC) has shown a declining trend though it may still be twice that as with open cholecystectomy. Major biliary or vasculobiliary injury is associated with significant morbidity. As prevention is the best strategy, the concept of a culture of safe cholecystectomy has been recently introduced to educate surgeons and apprise them of basic tenets of safe performance of LC. Various aspects of safe cholecystectomy include: (1) thorough knowledge of relevant anatomy, various anatomical landmarks, and anatomical variations; (2) an understanding of the mechanisms involved in biliary/vascular injury, the most important being the misidentification injury; (3) identification of various preoperative and intraoperative predictors of difficult cholecystectomy; (4) proper gallbladder retraction; (5) safe use of various energy devices; (6) understanding the critical view of safety, including its doublet view and documentation; (7) awareness of various error traps (e.g., fundus first technique); (8) use of various bailout strategies (e.g., subtotal cholecystectomy) in difficult gallbladder cases; (9) use of intraoperative imaging techniques (e.g., intraoperative cholangiogram) to ascertain correct anatomy; and (10) understanding the concept of time-out. Surgeons should be facile with these aspects of this culture of safety in cholecystectomy in an attempt to reduce the incidence of biliary/vascular injury during LC.
EUS Guided Interventions for Pancreatobiliary TumoursJarrod Lee
Endoscopic Ultrasound (EUS) has advanced rapidly in recent years, and has evolved from a primarily diagnostic tool, to one that has an increasing role in interventions. We review the latest roles of EUS guided interventions for pancreas and bile duct tumours.
The lecture was the plenary lecture at the Philippines National Endoscopy Conference 2014
Choledocholithiasis is one of the main causes for Obstructive Jaundice.In this ppt presentation, I have discussed the etiology, clinical features, complications, investigations and management of Choledocholithiasis. I have also included a mindmap and 2 algorithms for Choledocholithiasis. I hope you will find it very useful and interesting.
Common Bile Duct (CBD) is a tube that carries bile from gallbladder or liver to the small intestine. Gallstone may develop when there is too much cholesterol or bilirubin inside gallbladder secreted by the liver. CBD stones may not have any signs & symptoms for months or even years. However, if the blockage becomes severe, then some signs & symptoms may be experienced. For more information, visit at http://gisurgery.info
This is very important topic for Laparoscopic surgeons,as bile injury is not uncommon,how to approach such biliary injuries is prime to know for evolving surgeons.This slide would also helpful for surgery residents.
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
Laparoscopic exploration of the common bile duct (CBD) is performed either for the diagnosis or the treatment of CBD stones. CBD stones demonstrated by laparoscopic intraoperative cholangiography (IOC) or laparoscopic ultrasonography (LUS) are extracted either through the cystic duct or through choledochotomy.
2011 Debate on Chromoendoscopy for IBD colitis surveillanceRupert Leong
Chromoendoscopy and other advanced endoscopic imaging techniques are becoming the standard of care in the surveillance of dysplasia. At the 2011 Australian Gastroenterology Week, the use of advanced imaging techniques was compared against four quadrant random biopsies at a breakfast debate.
Comments Excellent paper. It’s obvious that you put quite a bit of .docxdrandy1
Comments: Excellent paper. It’s obvious that you put quite a bit of work into this. Unfortunately, your paper needs adequate citations in the body of the text to meet our standards on plagiarism. You need to cite each textbook from your bibliography whenever you quote or use some information from the textbook or other resource. For example, writing (Jones 285) after the quote or information used means that you got it from the book whose author was Jones and the info came from page 285.
Laparoscopic cholecystectomy is a procedure in which laparoscopic techniques remove the gallbladder. It is the standard of care for symptomatic gallbladder disease, of which most are performed for symptomatic cholelithiasis. Other indications include acute cholecystitis, biliary dyskinesia, and gallstone pancreatitis.
Describe the reasons a patient might have the selected surgical procedure
The typical reason a cholecystectomy is a treatment of choice is inflammatory changes of gallbladder or blockage of bile flow by gallstones. Symptomatic cholelithiasis is the most common reason where gallstones in the gallbladder are blocking the bile flow and cause inflammation. The patient usually complains of episodic epigastric pain and right upper quadrant pain that radiates to the right shoulder. This pain is found to occur several hours after heavy meals and the patient experiences nausea, vomiting, bloating, fever, and right upper quadrant tenderness. Another condition is acute cholecystitis, where inflammation and symptoms are more prominent. The patient may have a fever, constant pain, positive Murphy's sign, or leukocytosis. Acute cholecystitis may be caused by calculous biliary tract disease with confirmed gallstones in the abdominal US. Acute acalculous cholecystitis usually occurs in critically ill patients, those with prolonged total parenteral nutrition, and some immunosuppressed patients. Patients with episodes of right upper quadrant pain (which are ‘classic' for biliary pain without evidence of cholelithiasis of US or ERCP) may also be referred for laparoscopic cholecystectomy. Gallstone pancreatitis (when small stones pass through the cystic duct) confirmed by cholangiography is another indication for laparoscopic cholecystectomy.
Describe the reasons a patient might be disqualified for this surgery and the options for the patient if any
A patient might be excluded for laparoscopic cholecystectomy due to acute general conditions that are a contraindication for any surgery such as an acute cardiac failure, uncontrolled hypertension, acute renal failure, pneumonia, etc. The condition should be treated by a primary care provider or specialist and the patient should be stable prior surgery. Additional contraindications may include the inability to tolerate general anesthesia, significant portal hypertension, uncorrectable coagulopathy, and multiple prior operations.
List the diagnostic tests and lab work that an attending surgeon might order and desc.
Comments Excellent paper. It’s obvious that you put quite a bit of .docxcargillfilberto
Comments: Excellent paper. It’s obvious that you put quite a bit of work into this. Unfortunately, your paper needs adequate citations in the body of the text to meet our standards on plagiarism. You need to cite each textbook from your bibliography whenever you quote or use some information from the textbook or other resource. For example, writing (Jones 285) after the quote or information used means that you got it from the book whose author was Jones and the info came from page 285.
Laparoscopic cholecystectomy is a procedure in which laparoscopic techniques remove the gallbladder. It is the standard of care for symptomatic gallbladder disease, of which most are performed for symptomatic cholelithiasis. Other indications include acute cholecystitis, biliary dyskinesia, and gallstone pancreatitis.
Describe the reasons a patient might have the selected surgical procedure
The typical reason a cholecystectomy is a treatment of choice is inflammatory changes of gallbladder or blockage of bile flow by gallstones. Symptomatic cholelithiasis is the most common reason where gallstones in the gallbladder are blocking the bile flow and cause inflammation. The patient usually complains of episodic epigastric pain and right upper quadrant pain that radiates to the right shoulder. This pain is found to occur several hours after heavy meals and the patient experiences nausea, vomiting, bloating, fever, and right upper quadrant tenderness. Another condition is acute cholecystitis, where inflammation and symptoms are more prominent. The patient may have a fever, constant pain, positive Murphy's sign, or leukocytosis. Acute cholecystitis may be caused by calculous biliary tract disease with confirmed gallstones in the abdominal US. Acute acalculous cholecystitis usually occurs in critically ill patients, those with prolonged total parenteral nutrition, and some immunosuppressed patients. Patients with episodes of right upper quadrant pain (which are ‘classic' for biliary pain without evidence of cholelithiasis of US or ERCP) may also be referred for laparoscopic cholecystectomy. Gallstone pancreatitis (when small stones pass through the cystic duct) confirmed by cholangiography is another indication for laparoscopic cholecystectomy.
Describe the reasons a patient might be disqualified for this surgery and the options for the patient if any
A patient might be excluded for laparoscopic cholecystectomy due to acute general conditions that are a contraindication for any surgery such as an acute cardiac failure, uncontrolled hypertension, acute renal failure, pneumonia, etc. The condition should be treated by a primary care provider or specialist and the patient should be stable prior surgery. Additional contraindications may include the inability to tolerate general anesthesia, significant portal hypertension, uncorrectable coagulopathy, and multiple prior operations.
List the diagnostic tests and lab work that an attending surgeon might order and desc.
These slides are from versions of a talk I gave at ESTRO in 2014 and again in Lille in 2015.
The talk aims to explain the importance of correctly defining the CTV with respect to nodes in curative radiotherapy planning.
The lecture makes some important points about the function of lymph glands and their potential to act as stem cell 'rests' for malignant cells: this fact might explain whilst lymph node failure rates don't necessarily equate to disease failure rates.
The lecture then goes on to emphasise the utility of the best imaging technologies may more accurately identify involved nodes.
Shrinking fields with confidence may be the best way to reduce radiation toxicity.
TAPP and TEP in the Complicated Hernia: Scrotal, Strangulated, and Recurrent
Common Bile Duct Stones: Leave Them Get Them or Refer Them
1.
2.
3.
4.
5.
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. 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. 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. 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. 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.
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