View
1.773
Download
0
Category
Preview:
DESCRIPTION
This document was automatically uploaded to Scribd as part of the email thread "hi".
Citation preview
CURRENT TRENDS IN MANAGEMENT OF
CHOLEDOCHOLITHIASIS
S.K. SAHU
MODERATOR –
DR A. SILODIA
INTRODUCTION – CBD stones
Present in 10 – 15 % of cholecystectomy pts
Incidence rises with age, duration of gallstone symptoms
Associated with high rate of complications
Should always be removed
CLASSIFICATION – CBD Stones
By the point of origin1. Primary CBD Stones2. Secondary CBD Stones
By the time of discovery relative to cholecystectomy
1. Retained 2. Recurrent
PRESENTATION – CBD Stones
Biliary colic Jaundice Pale stools Darkening of urine Fever with chills – cholangitis Charcots triad, Reynolds pentad
LABORATORY INVESTIGATIONS
Elevated s. bilirubin,aminotransferase, alkaline phosphatase
May be normal in 1/3 of patients with CBD Stones
DIAGNOSING CBD STONES
USG– decreased sensitivity– retro and intraduodenal stones not visualized
EUS– increased sensitivity
ERCP– added advantage of being therapeutic in distal
stones
DIAGNOSING CBD STONES
MRCP not a therapeutic procedure does not have morbidity and mortality
associated with ERCP may avoid use of unnecessary invasive
procedures
Indications of MRCP
unsuccessful or contraindicated ERCP patient preference for non-invasive imaging patients considered to be at low risk of
having pancreatic or biliary disease; patients where need for therapeutic ERCP is
unlikely with a suspected neoplastic cause for
pancreatic or biliary obstruction
CBD Stone on USG
CBD Stone on EUS
CBD Stone on MRCP
CBD Stone on IOC
MANAGEMENT – CBD Stones
Open cholecystectomy + surgical exploration of the CBD – in the past/ centres where laparoscopy not available
ERCP + Endoscopic Sphincterotomy followed by cholecystectomy – most frequently used
Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in experienced hands
OPEN CBD EXPLORATION
Time tested method
Indicated if1. Stones detected during open
cholecystectomy2. Need for biliary enteric anastamosis3. Endoscopy difficult / risky4. Unsuccessful LCBDE5. Impacted/ multiple / larger stones
OPEN CBD EXPLORATION
Contraindicated in
1. Small CBD <5mm
2. Portal HT
3. Severe periportal inflammation
4. Cholangitis with septic shock
ERCP + ES - Indications
CBD Stones detected prior to cholecystectomy
High risk patients unfit for operation
Severe cholangitis / pancreatitis
CBD Stone on ERCP
ERCP + ES - complications
Pancreatitis(7%) Cholangitis Bleeding (2%) Perforation Abscess, recurrence Duodenobiliary reflux Rarely death
ERCP +ES - Limitations
Operator dependent
Cost & need for 2nd stage – a concern
Positive ERCP in only 34 % of cases
ADJUVANT TECHNIQUES with ERCP +ES
Mechanical lithotripsy
LASER lithotripsy
Electrohydraulic lithotripsy
ESWL
Chemical contact dissolution therapy
ADJUVANT TECHNIQUES - indications
Stones larger than the endoscope
Shape square/ piston shaped / faceted
Tightly packed stones/ hard stones
Intrahepatic stones
Stones proximal to CBD stricture
Laparoscopic CBD Exploration (LCBDE)
Components Laparoscopic cholecystectomy
Intraoperative cholangiography
Exploration if stone detected
LCBDE - Indications
Abnormal intraoperative cholangiogram or sonogram
Scintigraphic / endoscopic / radiographic evidence of bile duct stones
History of biliary pancreatitis
LCBDE - contraindications
Coagulopathy
Local porta pathology
Inability of surgeon to do LCBDE
Unfit patient
LCBDE - Approach
Transcystic
Choledochotomy
Transcystic LCBDE
Preferred approach Easy, more physiological Cystic duct should join CHD laterally or
posteriorly Indicated in small (<6mm), limited no of
stones(<5),absence of CHD stones
Laparoscopic choledochotomy
Used if cystic duct cant be dilated / intrahepatic pathology
Indicated in large (>6mm), more than 5 stones, CHD stones
Spiral course of cystic duct/ medial opening of cystic duct is an indication
LCBDE - advantages
Single admission/ short hospital stay
Reduced morbidity/ mortality
Success rate comparable to ERCP +ES
Failed LCBDE can be converted to open in the same sitting
LCBDE - limitations
Increased operative time / cost
Expertise not commonly available
SUSPECTED CBD Stones
jaundice No jaundice
Severe comorbidity Fit for surg
ERCP+ES
No further action
Lap chole+IOC
Stones
Operative removal
Post op ERCP
FailureThen choledochoduodenostomy
Failure thenRepeat surgery
MRCP
STONES present No stones
Lap choleunfit fit
Chole +ECBDERCP
CONCLUSION
CBD Stones associated in 10 – 15 % pts undergoing cholecystectomy
Advanced endoscopic & laparoscopic techniques have revolutionised management
Treatment depends on resources, technical limitations, surgeons expertise
LCBDE is safe, feasible, single stage management option for CBD stones
THANK YOU
Recommended