Common Bile Duct Stones: Leave Them Get Them or Refer Them

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Text of Common Bile Duct Stones: Leave Them Get Them or Refer Them

  • Common Bile Duct Stones:

    Joel A. Ricci, MD

    George Ferzli, MD, FACS

    Leave them
    get them
    or refer them

  • Objectives

    Pre-operative identification of risk factors associated with choledocholithiasis

    Learn different approaches in managing CBD stones

    Intra-operative decision making according to patients circumstances

    Recognize complications associated with different approaches

  • 1882 Langenbuch Cholecystectomy1889 Abbe Choledochotomy1890 Ludwig Courvoisier CBD exploration1932 Mirizzi Intraop cholangiography1941 McIver Rigid choledochoscopy1957 Wild Endoscopic ultrasound1968 McCune ERCP1986 Muhe LAP cholecystectomy1991 Wallner MRCP


  • Etiology

    Point of origin:

    Secondary (gallbladder)

    Primary (de novo within biliary tract)

    Primary CBD stones:

    South-east asian populations

    Associated with stasis and infection

    Brown pigment type

    Soft and easy to crumble

    Biliary stasis:

    Biliary stricture

    Papillary stenosis

    Sphincter of Oddi dysfunction

    Positive biliary cultures:


    Bacterial glucoronidases

    Deconjugation of bilirubin diglucuronide & precipitation of bilirubin as its

    calcium salt

  • Blood tests Transabdominal ultrasound ERCP Endoscopic ultrasound MRCP

    Preoperative Suspicion

  • * 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

  • Lezoche, E. Surg Endosc. 9(10), 1995

    Liver Function Tests

    LIVER FUNCTION TESTSINCIDENCE OF CBD STONESNORMAL4%One Abnormal Value20%Three Abnormal Values50%
  • Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996

    INDICATORSENSITIVITYSPECIFICITYCBDS on US0.381.00Cholangitis0.110.99Preop jaundice0.360.97Dilated CBD on US0.420.96Amylase0.110.95Pancreatitis0.100.95Jaundice0.390.92Bilirubin0.690.88Alk phos0.570.86Cholecystitis0.500.76
  • 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

  • Dilated


    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.

  • SENSITIVITY 75%-100%

    SPECIFICITY 77%-100%

    Rosch, TJ Gastro Surg. 5(3), 2001

    Endoscopic Ultrasound

  • Endoscopic Ultrasound

    STUDYNSensitivitySpecificityEdmundowicz (1992)2075%100%Palazzo (1995)42295%98%Prat (1996)11993%97%Sugiyama (1997)14296%100%Montariol (1998)24085%93%Polkowski (1999)5291%100%Materne (2000)5092%95%Lachter (2000)5097%77%
  • MRCP

    Sensitivity: 90%Specificity: 100%High costLimited availabilityNon therapeutic
  • Diagnostic and therapeuticInvasive studySuccess: 99%Mortality: 1%Morbidity: 6%Long term complications?

    Cotton, 1996


  • ERCP

    Diagnostic and therapeutic

    Endoscope into 2nd portion of duodenum

    Papilla visualized at 12 or 1 oclock

    Small nub across semicircular folds

    Soft reticulated area at tip = papillary orifice

    Cannulation of orifice


    CBD orifice at 11 oclock

    Pancreatic duct orifice at 1 to 2 oclock

  • ERCP

    CBD cannulation via guidewire


    Electrosurgical division of papilla

    Stone retrieval:

    Balloon sweep


    Crushing technique


    Cytologic brushings

    Balloon dilation

    Stent placement

  • ERCP


    Acinarization or rupture of small ductules

    Pancreatitis: contrast extravasation into duct

    Cholangitis: contrast into proximal biliary tree

    Duodenal perforation:

    Retroperitoneal or free intraperitoneal air Emergency surgery




    Balloon tamponade

    Arteriographicembolization of GDA

  • Indicated for patients with

    pancreatitis and concomitant


    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

    Prospective randomized trial on pts w/ resolving gallstones pancreatitis

    34 pts had Lap chole w/ Intra-op cholangiogram

    29 pts had preop MRCP

    If MRCP negative Lap chole w/ IOC

    If MRCP positive ERCP followed by Lap chole

    MRCP prediction of CBD stones

    Sensitivity: 100%Specificity: 91%Positive predictive value: 50%Negative predictive value: 100%Accuracy: 92%

    Hallal AH, et al. MRCP accurately detects common bile duct stones in resolving gallstones pancreatitis. JACS 2005;200(6):869-875

    Conclusion: Patients with resolving gallstones pancreatitis and a negative MRCP do not need pre-op ERCP or Intra-op cholangiogram

  • Intraoperative cholangiogramLaparoscopic ultrasoundIndocyanine green injection

    Intraoperative Suspicion



    filling defect

    Laparoscopic Cholangiogram

  • Advantages

    Identification of biliary anatomy

    Recognition of aberrant anatomy

    Early recognition of CBD injury

    Identification of CBD stones


    Increased OR timeIncreased costRequires advanced technical skills

    Laparoscopic Cholangiogram

  • Less time consuming (
  • Time consuming (>16 min) Film often inadequateLower success rate (47%)Visualization of anatomy more difficultDifficulty in differentiation between stones and air bubbles



  • Cost effective analysis of intra-op cholangiogram

    Decision analytic models for cost & benefit

    $100 more per routine IOC with every Lap chole

    Routine IOC would prevent 2.5 deaths per every 10,000 pts

    $390,000 cost per life saved

    $87,143 cost per CBD injury avoided w/ IOC

    Flum DR, Flowers C, Veenstra DL. A Cost-Effectiveness Analysis of Intraoperative Cholangiography in the Prevention of Bile Duct Injury During Laparoscopic Cholecystectomy. JACS 2003;193(3):272-280

  • Current trends regarding intra-op cholangiogram

    Survey performed among 4,100 general surgeons

    44% responders

    27% defined themselves as routine IOC users

    91% reported IOC use in >75% of Lap chole

    Academic surgeons less prone to use (15% vs 30%)

    Selective users more often low volume surgeons

    Routine users more often high volume surgeons

    Surgeons at greatest risk for causing common bile duct injury (inexperienced, low-volume surgeons) and those who have the greatest opportunity to train others are less likely to use IOC routinely. These represent target groups for quality-improvement intervention aimed at broader IOC use

    Massarweh NN, Flum DR, et al. Surgeon Knowledge, Behavior, and Opinions Regarding Intraoperative Cholangiography. JACS 2008;207(6):821-830

  • Laparoscopic Ultrasound

  • Advantages:

    Not time consuming (mean 8 min) (Santambrogio 1995)

    Safe (Jakimowicz 1993)

    Can be easily repeated at any stage of the operation (Rothlin 1994)

    High success rate (~90%) (Santambrogio 1995)

    High sensitivity (90%)and specificity (96%) (Oberlin 1994)

    Laparoscopic Ultrasound


    Failure to recognize biliary injuries (Santambrogio 1995) Increased cost Requires surgeon ability in performing ultrasound

    (Stiegman 1994)

    Inadequate examination of the distal CBD (Santambrogio 1995) Low resolution for anatomical details (Pietrabissa 1995)
  • Laparoscopic US as a good alternative to
    intraoperative cholangiography (IOC)during
    laparoscopic cholecystectomy:results of prospective study.

    685 IOC (-35 cannot canulate cystic duct ) , 269 LUS (-2 steatosis)

    IOC detected 4.5% CBDS; LUS 6%

    IOC sensitivity 96.9%, specificity 99.2%

    LUS sensitivity 100%,specificity 99.6%


    In this prospective study, LUS has been certainly as

    effective as IOC as a primary imaging technique for bile

    duct. It permitted to detect CBDS with a high specificity

    and sensitivity, and was not followed by an increase in


    Hublet A et al Laparoscopic US as a good alternative to intraoperative cholangiography during lap chole: results of prospective study ActaChir Belg. 2009 May-Jun Belgique.

  • Assessment of CBD using laparoscopic US during laparoscopic cholecystectomy

    115 consecutive patients, LUS successful in112.

    Low risk 7%; Intermediate 36.4%; High risk 78.9%.

    With increasing experience, LUS can become the

    routine method for evaluating the bile duct during

    LC. A more aggressive preoperative evaluation of

    CBD is mandated in the intermediate and high risk

    groups of patients suspected of having CBD stones.

    YAO CC et al Assessment of common bile duct using laparoscopic US during laparoscopic cholecystectomy Surg Laparosc Endosc Percut Tech 2009 Aug Taiwan.

  • Intraoperative cholangiography in combination with laparoscopic ultrasonography for the detectection of occult choledocholithiasis

    103 patients IOC+LUS. Physicians team blinded.

    Success rate : IOC 91.3%; LUS 100%