Transcript
Page 1: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

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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

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• 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

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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

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• Blood tests

• Transabdominal ultrasound

• ERCP

• Endoscopic ultrasound

• MRCP

Preoperative SuspicionPreoperative Suspicion

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* 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

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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

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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

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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

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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.

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SENSITIVITY 75%-100%

SPECIFICITY 77%-100%

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

Endoscopic UltrasoundEndoscopic Ultrasound

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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

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MRCPMRCP

• Sensitivity: 90%

• Specificity: 100%

• High cost

• Limited availability

• Non therapeutic

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• Diagnostic and therapeutic

• Invasive study

• Success: 99%

• Mortality: 1%

• Morbidity: 6%

• Long term complications?

Cotton, 1996

ERCPERCP

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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

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ERCPERCPCBD cannulation via guidewire

Sphincterotomy

• Electrosurgical division of papilla

Stone retrieval:

• Balloon sweep

• Basket

• Crushing technique

Strictures:

• Cytologic brushings

• Balloon dilation

• Stent placement

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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

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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

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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

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• Intraoperative cholangiogram

• Laparoscopic ultrasound

• Indocyanine green injection

Intraoperative SuspicionIntraoperative Suspicion

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STATIC DYNAMICfilling defect

Laparoscopic CholangiogramLaparoscopic Cholangiogram

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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

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• 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

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• 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

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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

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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

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Laparoscopic UltrasoundLaparoscopic Ultrasound

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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)

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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.

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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.

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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

Page 32: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

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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

Page 34: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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?

Page 35: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

Page 36: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

Page 37: Common Bile Duct Stones: Leave Them Get Them or Refer Them

Fogarty

BalloondilatationAmpulla

Basket

Irrigation+ Glucagon

Fluoroscopy

TransampullaryGuide-wire

Endos. Guidedsphincterotomy

Basket

Choledochoscopy

balloon dilatationCystic duct

Transcystic CBD

Transcystic ApproachTranscystic Approach

Page 38: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

Page 39: Common Bile Duct Stones: Leave Them Get Them or Refer Them

Fogarty

T-tube/no T-tube/endobiliary stent

Basket

Lithotripsy(laser or electro-

hydraulic)

Choledochoscopy

Irrigation+ glucagon

Transductal

Laparoscopic CholedochotomyLaparoscopic Choledochotomy

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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

Page 41: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

Page 42: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

Page 43: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

Page 44: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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

Page 45: Common Bile Duct Stones: Leave Them Get Them or Refer Them

Drainage ProceduresDrainage Procedures

Indications:• Multiple CBD stones

• Recurrent choledocholithiasis

• Unsuccessful sphincterotomy

• Impacted large CBD stones

• Markedly dilated CBD

Choices:

• Choledochoduodenostomy

• Transduodenal sphincteroplasty

• Choledochojejunostomy

Page 46: Common Bile Duct Stones: Leave Them Get Them or Refer Them

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]

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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

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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

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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%)

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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.

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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

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What to do?What to do?

ERCPMRCP

Lap CBDLUS

Lap Cholangiogram Transcystic CBD

Lap

Chole

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PREOPPREOP INTRAOPINTRAOP POSTOPPOSTOP

SonoSonoEUS EUS MRCPMRCPERCPERCP

Lap transcysticLap transcysticLap CBDLap CBDOpen CBDOpen CBD

ERCPERCP

ConclusionConclusion

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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

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• 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

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Postoperative ERCPPostoperative ERCP

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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

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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


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