Management of Concomitant Gallbladder Management of Concomitant Gallbladder and Common Bile Duct Stonesand Common Bile Duct Stones

Joint Hospital Surgical Grand RoundJoint Hospital Surgical Grand Round

19th October 201319th October 2013

Dr. Wong Chun LamDr. Wong Chun Lam

Pamela Youde Nethersole Eastern HospitalPamela Youde Nethersole Eastern Hospital

Hong Kong SARHong Kong SAR

BackgroundBackground

10-18% of patients with gallbladder stones harbor common bile duct 10-18% of patients with gallbladder stones harbor common bile duct stonesstones

Before development of laparoscopyBefore development of laparoscopy Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with

open cholecystectomyopen cholecystectomy Open cholecystectomy with exploration of common bile ductOpen cholecystectomy with exploration of common bile duct Open cholecystectomy with post-operative ERCPOpen cholecystectomy with post-operative ERCP

With advancement in laparoscopic surgeryWith advancement in laparoscopic surgery

Laparoscopic cholecystectomy (LC) + CBD exploration Laparoscopic cholecystectomy (LC) + CBD exploration (LCBDE)(LCBDE)

LC + Intra-operative ERCPLC + Intra-operative ERCP LC + Open cholecystectomyLC + Open cholecystectomy Pre-operative ERCP + LCPre-operative ERCP + LC LC + Post-operative ERCPLC + Post-operative ERCP

Factors affecting choice

Patient’s general conditionPatient’s general condition Previous operationPrevious operation Stone’s characteristics (size, number, location)Stone’s characteristics (size, number, location) Anatomy of biliary treeAnatomy of biliary tree Timing of discovery of CBD stonesTiming of discovery of CBD stones FacilitiesFacilities Expertise in laparoscopic surgery / ERCPExpertise in laparoscopic surgery / ERCP

Pre-operative ERCP + LCPre-operative ERCP + LC

Patient presenting with obstructive jaundice / cholangitis Patient presenting with obstructive jaundice / cholangitis / severe pancreatitis/ severe pancreatitis ERCP ERCP initial therapeutic procedure initial therapeutic procedure Followed by lap. cholecystectomy after condition improvedFollowed by lap. cholecystectomy after condition improved

AdvantageAdvantage Technical skill not demandingTechnical skill not demanding Minimizes operation timeMinimizes operation time

DisadvantageDisadvantage Two-stage procedureTwo-stage procedure Possible septic complications between two Possible septic complications between two

proceduresprocedures

LC + Laparoscopic CBD exploration LC + Laparoscopic CBD exploration (LCBDE)(LCBDE)

Failed endoscopic removal of CBD stonesFailed endoscopic removal of CBD stones CBD stones difficult for endoscopic removalCBD stones difficult for endoscopic removal

History of gastrectomyHistory of gastrectomy Multiple CBD stonesMultiple CBD stones Large CBD stonesLarge CBD stones

Advantage:Advantage: Single-stage procedureSingle-stage procedure

Disadvantage:Disadvantage: Technically demandingTechnically demanding Risks of bile duct complicationsRisks of bile duct complications

LCBDE (Transcystic approach)LCBDE (Transcystic approach)

Cystic duct is dilatedCystic duct is dilated

Balloon / flexible basket / choledochoscope through cystic duct to CBD Balloon / flexible basket / choledochoscope through cystic duct to CBD for stone retrieval for stone retrieval

Cystic duct closed with clips / suturesCystic duct closed with clips / sutures

ContraindicationsContraindications Biliary stones proximal to cystic duct junctionBiliary stones proximal to cystic duct junction Small cystic ductSmall cystic duct Spiral shape of cystic ductSpiral shape of cystic duct Large stonesLarge stones Multiple stonesMultiple stones

LCBDE (Choledochotomy)LCBDE (Choledochotomy) Longitudinal incision at anterior surface of CBDLongitudinal incision at anterior surface of CBD

Instruments inserted directly CBD to extract stonesInstruments inserted directly CBD to extract stones Electrohydraulic / Laser lithotripsyElectrohydraulic / Laser lithotripsy

Closure of CBD with sutures +/- placement of T-tubeClosure of CBD with sutures +/- placement of T-tube

IndicationsIndications Large stonesLarge stones Multiple stonesMultiple stones Ductal stones proximal to cystic duct junctionDuctal stones proximal to cystic duct junction

DisadvantageDisadvantage Technically demandingTechnically demanding Risk of bile duct stricture and bile leakRisk of bile duct stricture and bile leak

ContraindicationsContraindications CBD not dilatedCBD not dilated

On-table ERCPOn-table ERCP

Rendezvous techniqueRendezvous technique Guidewire inserted through cystic duct into duodenumGuidewire inserted through cystic duct into duodenum Guidewire caught by duodenoscopeGuidewire caught by duodenoscope Papillotome inserted over guidewire to facilitate CBD cannulationPapillotome inserted over guidewire to facilitate CBD cannulation

Advantage:Advantage: Single-stage procedureSingle-stage procedure 100% cannulation rate100% cannulation rate

Disadvantage:Disadvantage: Supine positioning may cause ERCP more difficultSupine positioning may cause ERCP more difficult Longer operation timeLonger operation time Stones may not be able to clear in one goStones may not be able to clear in one go Requires ERCP endoscopist / staff / equipments in operating Requires ERCP endoscopist / staff / equipments in operating

theatretheatre

Post-operative ERCPPost-operative ERCP

CBD stones noted intra-operativelyCBD stones noted intra-operatively Non dilated CBDNon dilated CBD No expertise in LCBDENo expertise in LCBDE

AdvantageAdvantage Technically not demandingTechnically not demanding

DisadvantageDisadvantage Two-stage procedureTwo-stage procedure Need another operation (CBD exploration) in case of failureNeed another operation (CBD exploration) in case of failure Increased hospital stay and costIncreased hospital stay and cost

Current EvidenceCurrent Evidence

Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + LCBDELC + LCBDE

112 patients with radiological / biochemical evidence of possible 112 patients with radiological / biochemical evidence of possible CBD stonesCBD stones

Pre-op ERCP + Pre-op ERCP + LCLC

(n=55)(n=55)

LC + IOC +/- LC + IOC +/- LCBDELCBDE

(n=57)(n=57)

P-valueP-value

CBD stone CBD stone detecteddetected

3131 1717 0.0070.007

CBD stone CBD stone clearedcleared

30 (98%)30 (98%) 15 (88%)15 (88%) 0.280.28

MorbidityMorbidity 9.1%9.1% 10.5%10.5% >0.99>0.99

MortalityMortality 0%0% 0%0% >0.99>0.99

Hospital stayHospital stay 6.6 days6.6 days 5.3 days5.3 days <0.05<0.05

Rogers SJ et al. Arch Surg 2010; 145(1):28-33. (US)

30 patients with GB stones and CBD stones confirmed on EUS / MRCP30 patients with GB stones and CBD stones confirmed on EUS / MRCP

Pre-op ERCP Pre-op ERCP + LC+ LC

(n=15)(n=15)

LC + LCBDELC + LCBDE

(n=15)(n=15)

P-valueP-value

CBD clearanceCBD clearance 86.7%86.7% 93.5%93.5% >0.05>0.05

MorbidityMorbidity 15.3%15.3% 13.3%13.3% >0.05>0.05

MortalityMortality 0%0% 0%0% >0.05>0.05

Hospital stayHospital stay 4 days4 days 4.2 days4.2 days >0.05>0.05

Bansal VK et al. Surg Endosc 2010; 24: 1986-1989. (India)

Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + LCBDELC + LCBDE

Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + on-table ERCPLC + on-table ERCP

91 patients with GB and CBD stones diagnosed by MRCP91 patients with GB and CBD stones diagnosed by MRCP

Pre-op ERCP Pre-op ERCP + LC+ LC

LC + on-table LC + on-table ERCPERCP

P-valueP-value

CBD clearanceCBD clearance 80%80% 95.6%95.6% >0.05>0.05

PancreatitisPancreatitis 0%0% 2.2%2.2% >0.05>0.05

MorbidityMorbidity 8.8%8.8% 6.5%6.5% >0.05>0.05

Mean hospital Mean hospital staystay

8 days8 days 4.3 days4.3 days <0.0001<0.0001

Total costTotal cost £3834£3834 £2829£2829 <0.05<0.05

Morino M et al. Ann Surg 2006; 244: 889-893. (Italy)

Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + on-table ERCPLC + on-table ERCP

Pre-op ERCP + Pre-op ERCP + LCLC

LC + on-table LC + on-table ERCPERCP

P-valueP-value

CBD clearanceCBD clearance 96.6%96.6% 90.2%90.2% >0.05>0.05

PancreatitisPancreatitis 12.7%12.7% 1.7%1.7% <0.05<0.05

MorbidityMorbidity 23%23% 8.5%8.5% <0.05<0.05

Mean hospital Mean hospital staystay

8 days8 days 5 days5 days <0.05<0.05

Total costTotal cost £2708£2708 £2414£2414 <0.05<0.05

Rabago LR et al. Endoscopy 2006; 38: 779-786. (Spain)

LC + LCBDELC + LCBDE vs vs post-op ERCPpost-op ERCP

LC + LCBDELC + LCBDE

(n=40)(n=40)

LC + Post-op ERCPLC + Post-op ERCP

(n=40)(n=40)

P-valueP-value

Stone Stone clearanceclearance

30 (75%)30 (75%) 30 (75%)30 (75%) >0.05>0.05

MorbidityMorbidity (17.5%)(17.5%) (15%)(15%) >0.05>0.05

MortalityMortality 00 00

Hospital stayHospital stay 1 days1 days 3.5 days3.5 days <0.05<0.05

80 patients noted to have CBD stones in operative cholangiogram 80 patients noted to have CBD stones in operative cholangiogram during lap. cholecystectomyduring lap. cholecystectomy

Rhodes et al. Lancet 1998; 351: 159-161. (UK)

LC + LCBDELC + LCBDE vs vs post-op ERCPpost-op ERCP 372 patients undergoing LC for symptomatic gallstones noted to have CBD 372 patients undergoing LC for symptomatic gallstones noted to have CBD

stones by transcystic cholangiographystones by transcystic cholangiography 286 patients achieved CBD clearance with transcystic approach286 patients achieved CBD clearance with transcystic approach Remaining 86 patients in which transcystic clearance was failedRemaining 86 patients in which transcystic clearance was failed

LC + LCBDELC + LCBDE

(n=41)(n=41)

LC + Post-op ERCPLC + Post-op ERCP

(n=45)(n=45)

P-valueP-value

Stone clearanceStone clearance 40 (97.6%)40 (97.6%) 43 (95.6%)43 (95.6%) >0.05>0.05

Severe Severe pancreatitispancreatitis

1 (2.4%)1 (2.4%) 1 (2.2%)1 (2.2%) >0.05>0.05

MorbidityMorbidity 7 (17%)7 (17%) 6 (13%)6 (13%) >0.05>0.05

Hospital stayHospital stay 6.6 days6.6 days 7.4 days7.4 days >0.05>0.05

Nathanson LK et al. Ann Surg 2005; 242: 188-192. (Australia)

ConclusionConclusion

Comparable stone clearance rate and morbidity between Comparable stone clearance rate and morbidity between all optionsall options

Single-stage proceduresSingle-stage procedures Potential benefit of reducing hospital stay / costPotential benefit of reducing hospital stay / cost Technically demandingTechnically demanding

Depends on patient conditions, stone characteristics, Depends on patient conditions, stone characteristics, facilities and expertisefacilities and expertise