0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99

ERCPs (OPCS4 J38:J45) recorded in any position

Laparoscopic cholecystectomy (OPCSJ08.8, J18+Y50.8)

Cholecystectomy & exploration of common bile duct (J18.2) recorded in any position

Calculus of bile duct with/without cholangitis or cholocystitis recorded in any position* with any or no procedure recorded

INCIDENCE OF REPEAT ERCP COMPARED TO TOTAL

0

500

1000

1500

2000

2500

3000

3500

4000

4500

5000

1989/90 1990/91 1991/92 1992/93 1993/94 1994/95 1995/96 1996/97 1997/98 1998/99

ERCPs (OPCS4 J38:J45) recorded in any positionERCP as main operation with ERCP recorded also as secondary procedure

ERCP in England 1990-1999

90/91 98/99 Increase %

Diagnostic; Surgery 5027 10400

Medicine 6169 11252

Total 11196 21652 190 %

Therapeutic; Surgery 2037 8162

Medicine 1980 8197

Total 4017 16359 400 %

All ERCP’s 15213 38011 250 %

ISD SCOTLAND 98/99

• Cholecystectomy total 5126• Laparoscopic cholecystectomy 3827

• Open or converted 25.3% 1299• ERCP 4792• SASM 1998, 164 ERCP deaths, 2.8 % 99 deaths in malignant dis., 99/949 (10.4 %) 65 deaths in benign conditions, 65/3000 (2.1 %) Therapeutic ERCP’s done in only 40 % !!

Neoptolemos J P,et alBr Med J. 1987;294:470-4

Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones

Results do not support routine preop ES on the basis of

efficacy, morbidity or costES/Surg Surgery

Number 55 60

Stone clearance 91% 91.5%

Major complications 16.4% 8.5%

Minor complications 16.4% 13.6%

RISK FACTORS FOR CBD STONES

• ACUTE PAIN & RAISED LFT’s• JAUNDICE & CBD DILATATION• CBD DILAT.& RAISED LFT• CBD DILAT. OR STONE ON USS• CHOLANGITIS & JAUNDICE• PANCREATITIS & RAISED LFT’s• DILATED CD OR CBD AT LC• CBD STONE ON PLAIN FILM

INDICATIONS FOR ERCP

• DIAGNOSTIC UNCERTAINTY, STONES LESS LIKELY ( IVC, PTC,MRC, EUS )

• SEVERE ACUTE CHOLANGITIS

• UNRESOLVING PANCREATITIS

• HIGH RISK, ELDERLY, UNFIT FOR LC

• RETAINED STONES

• FAILED TCE, SMALL DUCT

INDICATIONS IN THE LAPAROSCOPIC ERA

• Clear the CBD before cholecystectomy !

• Laproscopic IOC is time-consuming !

• Plan operating lists !

• No need for urgent biliary surgery !

• Laparoscopic CBDE is difficult !

Lein-Ray M O et al,J Laparoendosc Surg.1993;3:10-22• The role of ERCP and therapeutic biliary

endoscopy in LC

• Selection of 35 patients for preop ERCP, based on US and biochemical data

• Stones found in 16 (45.7%) >> ES

Berci G, J Laparoendosc Surg,1993:4:427

• ‘ .. More than half of the patients underwent,in my opinion, an unnecessary, risky and expensive examination’

• ‘.. Surgeons performing LC should nowadays consider advancing their technique in learning how to do laparoscopic choledocho-lithotomy

• ‘.. I think it is the wrong philosophy to divide biliary stone disease to be treated in two sessions or even by two disciplines’

TWO-SESSIONS APPROACH, THE PROBLEMS

• PREOPERATIVE ERCP NEGATIVE IN UP TO 50%

• ERCP AND ES FAIL IN 10-35%

• ERCP MORBIDITY AND MORTALITY

• ES-LC INTERVAL COMPLICATIONS

• LONG TERM MORBIDITY OF ES

• THE COST

Wilson MS, Common bile duct diameter and complications of endoscopic sphincterotomy

Br J Surg, 1992; 79:1346-7

• Study of 655 patients

• In experienced hands, 30 day mortality of 0.5-1.5% and morbidity of 2.5-11.3%

• ES more hazardous in small papilla or if CBD is undilated or tapers distally

• Relative risk of complications increased 10 times if the CBD diameter was >8mm

Cetta F, CBD stones in the era of LC: changing treatments and new

pathological entities. J Laparoendosc Surg 1994; 4:41-4

• Need to preserve the Sphincter of Oddi

• SS & ES—9-11% stone recurrence within 6 years increasing with time. Recurrent brown stones due to stasis & infection

• High rate of long term complications of ES

• Resist ES without proper indication even at expense of risk of increased complications in the first phases of LCBDE

ALTERNATIVES

• REPEATING THE USS

• INTRAVENOUS CHOLANGIOGRAPHY

• CT SCAN; PANCREAS , CBD

• MRC

• ENDOSCOPIC ULTRASOUND

• OPERATIVE CHOLANGIOGRAM

CONSERVATIVE MANAGEMENT

• PANCREATITIS

• JAUNDICE / CHOLANGITIS

• JAUNDICE / ACUTE CHOLECYSTITIS

• ACUTE PAIN & RAISED LFTs

LOW-THRESHOLD SELECTIVE

CHOLANGIOGRAPHY• THE “ OBVIOUS” CASE• ADMISSION WITH SEVERE PAIN• DERANGEMENT OF “ANY” LFT• RECENT JAUNDICE• RECENT PANCREATITIS• MULTIPLE SMALL STONES ON USS• CD STONE/DILAT. OR DILATED CBD• PREVIOUS ERCP – ES ; RECENT OR OLD

INDICATIONS FOR TCE

• SMALL STONES IN DISTAL CBD

• DILATED OR DILATABLE CD !!

• FACTORS TO CONSIDER : ANATOMY , NUMBER OF STONES, INSTRUMENTS

INDICATIONS FOR LCBDE

• LARGE, MULTIPLE OR PROXIMAL STONES

• FAILED TCE- CBD 8 mm +

• RETAINED STONES- FAILED ERCP

PREPARATION

• TRAINING

• STAFF

• IMAGING

• INSTRUMENTS

• CHOLEDOCHOSCOPE

• PATIENCE

ACCESS PORTS

• TYPE ; GRIP - VALVES

• PLACEMENT ; SITES - ANGLE - DISTANCE

• OPTIMAL USE ;

• SUTURING

• CHOLEDOCHOSCOPY

TRANSCYSTIC EXPLORATION

• INDICATIONS

• DILATING THE DUCT ??

• IMAGE GUIDED EXPLORATION ; WHEN ? - PRECAUTIONS - PITFALLS

• CHOLEDOCHOSCOPE EXPLORATION DORMIA IN CHANNEL, PROBE ON CHD, LOW IRRIGATION

• STONE RETRIEVAL / TRANSFERE

TRANSCYSTIC EXPLORATION

• GLUCAGON

• BALLOON SPHINCTER DILATATION

• COMPLETION CHOLANGIOGRAM

• CYSTIC DUCT;TIE,CLIP, LOOP,DRAIN

• CAUSES OF FAILURE

• COMPLICATIONS

CHOLEDOCHOTOMY PREPARATION

• DISSECTING THE PEDICLE

• EXPOSING THE CBD

• SECURING THE CYSTIC DUCT ?CBDE - DEFINITE CBDE

• IOC ; CD - CBD

• IOC ; ANATOMY , SIZE OF CBD - NUMBER , SIZE , SITE OF STONES

CHOLEDOCHOTOMYTECHNIQUE

• EXPOSURE

• OPENING THE DUCT; POSITION, SIZE, TOOLS

• METHODS OF STONE RETRIEVAL; IRRIGATION, BALLOON, DORMIA, GRASPER

• CHOLEDOCHOSCOPIC CONTROL; CBD, INTRAHEPATIC DUCTS

• CHOLED/SCOPIC CHOLANGIOGRAM

CHOLEDOCHOTOMYDIFFICULT CASES

• MULTIPLE

• LARGE

• INTRAHEPATIC

• IMPACTED

• S- SHAPED DUCT

CHOLEDOCHOTOMYCLOSURE

• PRIMARY

• DRAINAGE; CD or T-TUBE

• COMPLETION CHOLANGIOGRAM ?

• CARE DURING GB DISSECTION

• SUBHEPATIC DRAIN

• SUCTION OF IRRIGATION FLUID

• SECURING THE T-TUBE

CBD EXPLORATIONS

• OPERATING TIME 1 H - 4 H 45M ( 2.20)• MEAN HOSPITAL STAY 5.6 DAYS

(ALL EPISODES)• ADMISSION EPISODES 1.2 / PATIENT• PRESENTATION TO RESOLUTION 20 D

Complications of ES are often more serious and directly related to the procedure

• Haemorrhage

• Duodenal perforations

• Pancreatitis

• Biliary sepsis

BERTHOU,ET AL. FRANCEJAN 97, EUR.J.COELIO SURG

• 200 CASES IN 6 YEARS• AGE 22-93 MEAN 63• PREOP DIAGNOSIS 59 % , IOC 41%• TCE 101, SUCCESS 68 ;

27 CBDE , 6 ERCP & ES • CHOLEDOCHOTOMY 126, OK 122, 97%

FAILED 4, OPEN 3, ES 1 • MAJOR MORBIDITY 1% MINOR 8%

RET STONES 3.5%, 1 STRICTURE 19/12

MARTIN ET AL, BRISBANEBR J SURG, 98, 85, 412

• 300 CASES IN 6 YEARS, ONE DEATH

• AGE 19-100 MEAN 56

• OPERATION TIME 95 MIN ( 35-300)

• TCE 171 ( STENT IN 3 )

• CBDE 129 , 12 CONVERSIONS ( 4% )

• POSTOP ERCP 21 , STONES 9 (3% )

• MAJOR MORBIDITY 7 % , REOP 3%

PAGANINI, LEZOCHE. ITALYSURG ENDOSC, 98, 12,23-29

• 161 CASES IN 5 YEARS. ONE DEATH

• 157 EXPLORATIONS;TCE 107,CBDE 50

• CONVERSION 4 ( 2.4%), RETAINED STONES 8 (5%)

• MAJOR MORBIDITY 6 ( 3.8%)

• RECURRENT STONES 5 (3.2%)

• CONSERVATIVE AND SURGICAL MANAGEMENT OF SUSPECTED CBD STONES SAVES 89% AN ERCP

• LAPAROSCOPIC MANAGEMENT - APPLIES TO ALL PATIENTS FIT FOR LC - AVOIDS ERCP COST , MORBIDITY& MORTALITY

• LOW RATES OF MORBIDITY, RETAINED STONES AND CONVERSION.

• TRAINING, SUBSPECIALISATION, COST AND CLINICAL GOVERNANCE IMPLICATIONS