Common Bile Duct Stones:Common Bile Duct Stones:
Joel A. Ricci, MD
George Ferzli, MD, FACS
Leave them Leave them get them…get them…or refer themor refer them
ObjectivesObjectives
• Pre-operative identification of risk factors associated with choledocholithiasis
• Learn different approaches in managing CBD stones
• Intra-operative decision making according to patient’s circumstances
• Recognize complications associated with different approaches
• 1882 Langenbuch – Cholecystectomy
• 1889 Abbe – Choledochotomy
• 1890 Ludwig Courvoisier – CBD exploration
• 1932 Mirizzi – Intraop cholangiography
• 1941 McIver – Rigid choledochoscopy
• 1957 Wild – Endoscopic ultrasound
• 1968 McCune – ERCP
• 1986 Muhe – LAP cholecystectomy
• 1991 Wallner – MRCP
HistoryHistory
EtiologyEtiologyPoint 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:• Stasis• Bacterial glucoronidases• Deconjugation of bilirubin diglucuronide & precipitation of bilirubin as its
calcium salt
• Blood tests
• Transabdominal ultrasound
• ERCP
• Endoscopic ultrasound
• MRCP
Preoperative SuspicionPreoperative 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
INCIDENCE OF CBD STONES
NORMAL 4%
One Abnormal Value20%
Three Abnormal Values50%
Liver Function TestsLiver Function Tests
Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996
INDICATORINDICATOR SENSITIVITYSENSITIVITY SPECIFICITYSPECIFICITY
CBDS on USCBDS on US 0.380.38 1.001.00
CholangitisCholangitis 0.110.11 0.990.99
Preop jaundicePreop jaundice 0.360.36 0.970.97
Dilated CBD on USDilated CBD on US 0.420.42 0.960.96
AmylaseAmylase 0.110.11 0.950.95
PancreatitisPancreatitis 0.100.10 0.950.95
JaundiceJaundice 0.390.39 0.920.92
BilirubinBilirubin 0.690.69 0.880.88
Alk phosAlk phos 0.570.57 0.860.86
CholecystitisCholecystitis 0.500.50 0.760.76
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 CBD
Transabdominal UltrasoundTransabdominal UltrasoundTest of choice for detecting cholelithiasis and common
bile duct dilatationLow 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 UltrasoundEndoscopic Ultrasound
STUDY N Sensitivity
Specificity
Edmundowicz (1992)
20 75% 100%
Palazzo (1995) 422 95% 98%
Prat (1996) 119 93% 97%
Sugiyama (1997) 142 96% 100%
Montariol (1998) 240 85% 93%
Polkowski (1999) 52 91% 100%
Materne (2000) 50 92% 95%
Lachter (2000) 50 97% 77%
Endoscopic UltrasoundEndoscopic Ultrasound
MRCPMRCP
• Sensitivity: 90%
• Specificity: 100%
• High cost
• Limited availability
• Non therapeutic
• Diagnostic and therapeutic
• Invasive study
• Success: 99%
• Mortality: 1%
• Morbidity: 6%
• Long term complications?
Cotton, 1996
ERCPERCP
ERCPERCP
Diagnostic and therapeutic
Endoscope into 2nd portion of duodenum
Papilla visualized at 12 or 1 o’clock
• Small nub across semicircular folds
• Soft reticulated area at tip = papillary orifice
Cannulation of orifice
• Fluoroscopy
• CBD orifice at 11 o’clock
• Pancreatic duct orifice at 1 to 2 o’clock
ERCPERCPCBD cannulation via guidewire
Sphincterotomy
• Electrosurgical division of papilla
Stone retrieval:
• Balloon sweep
• Basket
• Crushing technique
Strictures:
• Cytologic brushings
• Balloon dilation
• Stent placement
ERCPERCP
Complications
• 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
• Bleeding:Epinephrine
Electrocoagulation
Balloon tamponade
Arteriographicembolization of GDA
Indicated for patients with pancreatitis and concomitantcholangitis.
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.
ERCPERCP
ERCPERCPProspective 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 cholangiogram
• Laparoscopic ultrasound
• Indocyanine green injection
Intraoperative SuspicionIntraoperative Suspicion
STATIC DYNAMICfilling defect
Laparoscopic CholangiogramLaparoscopic Cholangiogram
Advantages • Identification of biliary
anatomy
• Recognition of aberrant anatomy
• Early recognition of CBD injury
• Identification of CBD stones
Disadvantages• Increased OR time
• Increased cost
• Requires advanced technical skills
Laparoscopic CholangiogramLaparoscopic Cholangiogram
• Less time consuming (<5 mn)• Better quality and higher
resolution• Higher success rate (99%)• Possibility of interaction with
the findings• Required for transcystic
exploration of CBD• Limited availability
Cuschieri 1994
CholangiogramCholangiogramDynamicDynamic
• Time consuming (>16 min)
• Film often inadequate
• Lower success rate (47%)
• Visualization of anatomy more difficult
• Difficulty in differentiation between stones and air bubbles
CholangiogramCholangiogramStaticStatic
Cost effective analysis of intra-op Cost effective analysis of intra-op cholangiogramcholangiogram
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 Current trends regarding intra-op cholangiogramcholangiogram
Survey performed among 4,100 general surgeons44% responders27% defined themselves as routine IOC users91% reported IOC use in >75% of Lap choleAcademic surgeons less prone to use (15% vs 30%)Selective users more often low volume surgeonsRoutine 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 UltrasoundLaparoscopic 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 UltrasoundLaparoscopic Ultrasound
Disadvantages• 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 Laparoscopic US as a good alternative to intraoperative cholangiography (IOC)duringintraoperative cholangiography (IOC)during laparoscopic cholecystectomy:results of laparoscopic cholecystectomy:results of prospective study.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% Results: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 CBDI.
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 Assessment of CBD using laparoscopic US during laparoscopic cholecystectomyduring 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 Intraoperative cholangiography in combination with laparoscopic ultrasonography for the with laparoscopic ultrasonography for the detectection of occult choledocholithiasisdetectection of occult choledocholithiasis
103 patients IOC+LUS. Physicians team blinded.
Success rate : IOC 91.3%; LUS 100%
Time required for LUS was shorter.
The sensitivity of IOC combined with LUS was 92.9% which was greater than of IOC and LUS taken separately.
LUS is usually performed in case where IOC has failed or is
contraindicated. The combination of both methods maximizes
intraoperative detection of occult CBD stones and should at least
be recommended as two complementary methods.
LI JW et al Intraoperativecholangiogram in combination with laparoscopic us for the detection of occult choledocholithiasis Med SciMonit. 2009 Sept China
Indocyanine Green (ICG) Injection:Indocyanine Green (ICG) Injection:
Shows the confluence between right and left hepatic
ducts during hepatectomy
Enables identification of the cystic duct and CBD
from before dissection of Calot’s triangle during
cholecystectomy
Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009; 208(1):e1-e4
Indocyanine Green Injection (ICG)Indocyanine Green Injection (ICG) AdvantagesAdvantages
• No need for dissection of Calot’s triangle
• No need for insertion of trans-cystic tube
• No exposure to radiation
• No space-occupying C-arm machine required
• Simple and convenient procedure
• Allergic reactions
Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;208(1): e1-e4
Intra-operative Decision MakingIntra-operative Decision Making
• Convert to open?
• Laparoscopic transcystic common bile duct exploration?
• Laparoscopic cholechotomy?
• Defer to post-op management?
• Open or laparoscopic biliary bypass?
• Transduodenal papillotomy?
• Combined laparoscopy + ERCP?
Factor Transcystic Choledochotomy
One stone + +
Multiple stones + +
Stones < 6mm + +
Stones > 6mm - +
Intra-hepatic stones - +
Cystic duct < 4mm - +
Cystic duct > 4mm + +
CBD < 6mm + -
CBD > 6mm + +
CD entrance: lateral + +
Entrance: posterior - +
Entrance: distal - +
Mildly inflamed + +
Markedly inflamed + -
Suturing: poor + -
Suturing: good + +
Factors influencing approach to the common bile ductFactors influencing approach to the common bile duct
Transcystic:• Stone < 6 mm
• Cystic duct > 4 mm
• CBD < 6 mm
• Lateral entrance of cystic duct
• Severe or mild inflammation
• Poor suturing ability
1998, Petelin
Laparoscopic CBD ExplorationLaparoscopic CBD Exploration
Transductal:• Stone > 6 mm
• Cystic duct < 4 mm
• CBD > 6 mm
• Posterior or distal entrance of cystic duct
• Mild inflammation
• Good suturing ability
Fogarty
BalloondilatationAmpulla
Basket
Irrigation+ Glucagon
Fluoroscopy
TransampullaryGuide-wire
Endos. Guidedsphincterotomy
Basket
Choledochoscopy
balloon dilatationCystic duct
Transcystic CBD
Transcystic ApproachTranscystic Approach
STUDYSTUDY NN SUCCESS (%)SUCCESS (%)
FERZLI, 1991FERZLI, 1991 1313 100100
SAGES, 1994SAGES, 1994 187187 9595
PHILLIPS, 1994PHILLIPS, 1994 111111 9191
DePAULA, 1994DePAULA, 1994 102102 8484
BERTHOU, 1994BERTHOU, 1994 7878 6767
McGRATH, 1994McGRATH, 1994 4444 9393
DION, 1994DION, 1994 1818 9494
STOKER, 1995STOKER, 1995 3333 9494
Transcystic ApproachTranscystic Approach
Fogarty
T-tube/no T-tube/endobiliary stent
Basket
Lithotripsy(laser or electro-
hydraulic)
Choledochoscopy
Irrigation+ glucagon
Transductal
Laparoscopic CholedochotomyLaparoscopic Choledochotomy
Study Totalpatients
Success (%)
Berthou 94 75 96Franklin 94 60 96Dion 94 41 93SAGES 94 39 81Stoker 95 27 94DePaula 94 12 100Ferzli 91 11 100Phillips 95 3 100McGrath 94 1 100
Laparoscopic CholedochotomyLaparoscopic Choledochotomy
Study Patients Retainedstone
Morb. Mort. Lenth ofstay
SAGES 226 2.6 5.7 0.4 ?Berthou 153 1.3 9.4 0 ?Phillips 114 3.6 17.1 0.9 3.7DePaula 114 0.9 6.2 0.9 1.7Petelin 77 1.5 10.4 0.8 1.9Franklin 60 0 3.3 1.6 2.1Stoker 60 5 10 0 2.7Dion 59 5 25 0 12McGrath 45 2.2 26.7 0 ?Ferzli 24 8.3 29.1 0 2.7
Ferzli
Complications of Lap. CBD ExplorationComplications of Lap. CBD Exploration
TechniquesTechniques
Irrigation:
• Transcystic flushing
• IV glucagon
• Fluoroscopic monitoring
Balloon:• 4 Fr Fogarty balloon combined with choledochoscope
Basket:Avoid capture of papilla of Vater
Choledocoscopy / completion cholangiogram
• Primary closure of CDB vs T-tube placement
Combined Laparoscopy and ERCPCombined Laparoscopy and ERCP
• 45 pts underwent lap chole w/ intra-op cholangiogram
• 33 pts had succesful intra-op ERCP with extraction of CBD stones
• No post-op complications related to procedure (i.e. pancreatitisbleeding, perforation)
• Mean hospital stay: 2.55+0.89 days
• No pts w/ signs or symptoms of retained CBD stones during mean post-op follow-up of 9+4.07 monthsGhazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of
gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7(4):338-46
Current TrendsCurrent Trends
National Hospital Discharge Survey database 1979 to 2001:• Frequency of ERCP vs CBDE• Beginning of study: 47,000 CBDE’s per year• End of study: 7,000 CBDE vs 43,000 ERCP• Complication rates from CBDE
3.4% at beginning of study 17.4 at end of study
“ERCP has replaced the need for most but not all CBDE”
“Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CBDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CBDE experience”
Livingstion EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433
Drainage ProceduresDrainage Procedures
Indications:• Multiple CBD stones
• Recurrent choledocholithiasis
• Unsuccessful sphincterotomy
• Impacted large CBD stones
• Markedly dilated CBD
Choices:
• Choledochoduodenostomy
• Transduodenal sphincteroplasty
• Choledochojejunostomy
CostCost
Hospital cost in management of CBD stones• 53 pts underwent one-stage or two-stage procedure for CBD stone• One stage: Lap CBD exploration + lap chole• Two stage: ERCP followed by lap chole• 38 pts underwent cost analysis due to uneventful post-op course• Hospital stay: One stage: 2 (0-6) days Two stage: 8 (3-18) days
•Significantly lower costs after one-stage approach
•Total hospital cost: 2,636 vs 4,608 euro
•Hospitalization cost: 701 vs 2,190 euro
•Pharmaceutics cost: 645 vs 1,476 euro
•Para-medic personnel: 1,035 vs 1,860 euro
•OR cost (comparable): 1,278 vs 1,232 euroTopal B et al. Hospital cost categories of one-stage versus two-stage management of common bile duct stones. SurgEndosc 2009 Jun 25. [Epub ahead of print]
Postoperative ManagementPostoperative Management
• Post-op ERCP
• LithotripsyMechanical (crushing technique)Extra-corporeal shock wave (electromagnetic)Intra-corporeal (laser)
• Percutaneous radiologic
• Dissolution (chemical infusion)Mono-octanoinMethyl tert-buthyl ether (MBTE)
• Ursodeoxycolic acid Prevention
Treatment of difficult bile duct stones: a Treatment of difficult bile duct stones: a particularly safe option for octogenariansparticularly safe option for octogenarians
Ten years (1995-2006) : 44 patients median age 80.
Success in 34 (77%). The others required multiple attempts. All but one achieved complete clearance.
Peroral endoscopic electrohydrolic lithotripsy(EHL) or
laser lithotripsy (ILL), under direct cholangioscopic
visualisation, is an effective treatment for difficult CBD
stones. The technique can be used safely even in frail
and elderly patients. The vast majority of patients may
be expected to remain symptom-free for a prolonged
period.
Swahn F et al Ten Years of Swedish experience with intraductal electrohydrolic lithotripsy (EHL) and laser lithotripsy (ILL) for the treatment of difficult bile duct stones: an effective and safe option for octogenarians Surg Endosc. 2009 Oct 23
Extracorporeal shock wave lithotripsy: analysis Extracorporeal shock wave lithotripsy: analysis of factors that favor stone fragmentationof factors that favor stone fragmentation
A high success rate, negligible complications and
non-invasive nature of the procedure make ESWL a
useful tool for removing large CBD stones
Tandan M et al Extracorporeal shock wave lithotripsy of large difficult common bile duct stones: efficacy and analysis of factors that favor stone fragmentation J Gastroenterology Hepatol. 2009 Aug India.
283 patients with large CBDS were subjected to ESWL . CBDS wereFragmented to 5mm or less then extracted via ERCP.Complete clearance achieved in 239 patients(84.4%),partial in 35 (12.3%)
Risk factors for recurrent bile duct stones Risk factors for recurrent bile duct stones after endoscopic clearance of CBD stonesafter endoscopic clearance of CBD stones
114 patients (2004-2007) S/P ERCP.
The recurrence of CBD stones was more commonly
found in the patients group with type 1 periampullary
diverticulum and multiple sessions of ERCP.
Therefore, patients with these risk factors should be
on regular follow up.
Baek YH et al Risk factors for recurrent bile duct stones after endoscopic clearance of common bile duct stones Korean J Gastroenterol. 2009 Jul Korea.
ConclusionConclusion
• Multidisciplinary approach to CBD stones
• Pre-operative identification based on risk factors
• Laparoscopic CBD exploration is safe, cost-effective and carries low morbidity and mortality rate
• Surgeon experience determines:
Lap vs Open approach
Type of drainage procedure if necessary
LAP. CHOLE + CBD STONELAP. CHOLE + CBD STONE
ERCP skillsERCP skillsAvailability of Availability of equipmentequipment
Technical skillsTechnical skills
What to do?What to do?
ERCPMRCP
Lap CBDLUS
Lap Cholangiogram Transcystic CBD
Lap
Chole
PREOPPREOP INTRAOPINTRAOP POSTOPPOSTOP
SonoSonoEUS EUS MRCPMRCPERCPERCP
Lap transcysticLap transcysticLap CBDLap CBDOpen CBDOpen CBD
ERCPERCP
ConclusionConclusion
Transcystic ExplorationTranscystic Exploration
Laparoscopic vs Open• Stones larger than duct Dilatation
• Irrigation
• Fluoroscopic wire basketStones smaller than 2 to 4 mmClockwise rotation while retracting basketCare not to pull stones into hepatic ducts
• Endoscopic approachCholedochoscopebasketing
• Long, spiraling, medially inserting cystic ductCholedochotomy
• 08% Normal exam
• 33% CBD stones
• 25% Biliary injury
• 100% Success for stone removal
• 86% Success for biliary injuries
• 05% Complication
Kozarek, Surg Endosc 1995 Nov;9(11):1235-40
ERCPERCP
Postoperative ERCPPostoperative ERCP
WHAT TO DO? WHAT TO DO? WHAT TO DO? WHAT TO DO? E
RC
PE
RC
P
lap CBD
lap CBD
EUSEUS
IOC
IOC
MR
CP
MR
CP
Lap USLap US
CholedochotomyCholedochotomy
• Laparoscopic vs Open
• Large stones: > 1cm
• Anterior wall dissection 1-2 cm distance
• Stay sutures bilaterally
• Vascular supply @ 3 and 9 o’clock
• Longitudinal incision anterior aspect
• Choledochoscope inserted
• Irrigation, basket retrieval, lithotripsy
• 12 or 14 Fr T-tube positioned
• CBD closure over T-tube
• Primary closure of CBD
• Completion cholangiogram