Single-stage ercp followed by lap chole

1. Morbidity Meeting
UNIT B2
Dr.Bakri Hasan
Dr Nabeel Riadh
Dr.Yasir
Dr.A.Zidan
Single-stage procedure
for the management of
CBD Stone

2. Case summary
■ Miss Dabiah Ghanim 21 yrs. admitted through ER on 17-01-2024 complaining of Pain
epigastrium and multiple episodes vomiting for 2 days, But these symptoms were
recurring for the past 6 months..
■ Clinically there was a tender Right Hypochondrium , + VE Murphy's Sign with the rest of
abdomen was soft and lax.
■ As we traced back the past recent history , patient had repeated visits to the hospital
from 22-08-2023 to 17-01-2024 (6 months).
■ In the first visit, she was seen by Ortho in emergency for upper back pain and was
discharged from the emergency department.
■ She was having no other comorbidities.

3. Case summary
cont.
■ TLC-13000,HB-14 BIL-35/20 ,ALT/AST 306/440 and diagnosed has made as Biliary
cholecystitis with sign and symptoms of obstructive jaundice.
■ USG showed GBS and left adnexal cyst seen by department of gynae in their respective
referral and decided that the patient will be followed in OPD after her discharge from
surgical ward.
■ Gastroenterology seen the patient and initially advised MRCP 22-01-24 then they
decided to go for ERCPS 23-01-24 according to the MRCP findings.

4. Case summary
cont.
■ Decision had taken by unit A1 initially and had planned for Lap Chole on 25-01-24.
■ As soon they did pre-op round on 24-01-2024 and evaluated post ERCPS patient pre-op
planned Lap condition they founded deranged recent post ERCP LFTS, So they
consulted again the Gastro dept.
■ So, on 26-02-24 the gastro department did the ERCP again.

5. Case summary
cont.
■ And finally, this patient was taken over to proceed for Lap.Chole on 01-02-2024 after
mutual agreement of Unit A-1 with Unit B-2.
■ Per-Operative findings were staright farward and the whole procedure was un-eventful.
■ Post Operative patient recovery was excellent and dischaged on 04-02-2024
■ The patient was advised to visit the surgical OPD on the following Thursday for post-
operative follow-up and likewise advised to visit the
Gastro OPD after 6 weeks for CBD **Stent Removal**.

6. Learning Objectives
1. Why we place this case in morbidity meetings?
2. Treatment strategies regarding such case in Jahra Hospital and their outcome.
3. Recent advances for management of CBDS.
4. Literature review.
5. Audence opinion & discussion

7. 1:- Why we place this case in morbidity
meetings?
■ Unnecessary prolonged hospital stay due to benign
obstructive jaundice.
■ Multiple hospital visits & admission.
■ Repeated ERCP with CBD cannulations.
■ Long Hospital stay e.g. Total 18 days (17-01-2024 to
04-02-2024).
■ Another visit is still due for retain CBD stent removal.
■ IIIA OR IIIA if GA need in uncooperative patient for
repeated ERCP procedure.(Clavien Dindo Scale of
Surgical Complications).

8. Treatment strategies of cholecystico-
choledocholithiasis in our set up Jahra Hospital .
■ Patient Hx and clinical assessment
■ Labs CBC + Adm Profile , Amylase , Lipase , Coagulation Profile
■ X-ray Chest,Abdomen Erect and Supine.
■ USG abd + Pelvic
■ Gastro Refferal
■ MRCP or ERCP + (with or without stenting)
■ Post ERCP Patient optimization and fitness through anesthetist consultation.
■ 24-48 Hours Later Lap Chole
■ Generally, patients are discharged after 2 or more days according to the post-
op recovery phase, if there are no complications.

9. Diagnostic and possible Therapeutic measures along
stratification of patient with suspected CBD stone
■ Trans abdominal USG
■ MRCP
■ ERCP
■ Endoscopic USG
■ Laparoscopic intra-operative ultrasonography
■ Intraductal ultrasonography
■ Intraoperative cholangiography
■ Helical computed tomography
■ Intravenous cholangiography (e.g. ICG, iodine-containing dye (meglumine
ioglycamate)

10. Recent advances for the
management of CBDS?
1. Single-Stage Simple Intra-Operative ERCP and Laparoscopic Cholecystectomy.
2. Single –Stage Intraoperative rendezvous ERCP and Laparoscopic Cholecystectomy.
3. Single –stage trans-cystic laparoscopic bile duct clearance (TC-CBDE);
4. Single-Stage Intraoperative Laparoscopic CBD Exploration and Laparoscopic
Cholecystectomy evaluated the effectiveness of the clearance using a choledocoscope
followed by T-tube placement.

11. Conventional methods for the
management of CBDS?
■ Open Chole + CBD exploration with T-tube Placement.
■ Choledocho-Duadenostomy /Choledochojejunostomy (Hepatico-Jejunosotomy)

12. Literature Review

13. Literature Review

14. Literature Review

16. Thanks
Your Opinions
&
Questions