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

Common Bile Duct Stones: ,[object Object],[object Object],Leave them get them… or refer them

Objectives ,[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],History

Etiology ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Preoperative Suspicion ,[object Object],[object Object],[object Object],[object Object],[object Object]

* 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 TESTS INCIDENCE OF CBD STONES NORMAL 4% One Abnormal Value 20% Three Abnormal Values 50%

Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996 INDICATOR SENSITIVITY SPECIFICITY CBDS on US 0.38 1.00 Cholangitis 0.11 0.99 Preop jaundice 0.36 0.97 Dilated CBD on US 0.42 0.96 Amylase 0.11 0.95 Pancreatitis 0.10 0.95 Jaundice 0.39 0.92 Bilirubin 0.69 0.88 Alk phos 0.57 0.86 Cholecystitis 0.50 0.76

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 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 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%

MRCP ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cotton, 1996 ERCP

ERCP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

ERCP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Indicated for patients with pancreatitis and concomitant cholangitis. 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

ERCP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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

[object Object],[object Object],[object Object],Intraoperative Suspicion

STATIC DYNAMIC filling defect Laparoscopic Cholangiogram

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Laparoscopic Cholangiogram

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Cuschieri 1994 Cholangiogram Dynamic

[object Object],[object Object],[object Object],[object Object],[object Object],Cholangiogram Static

Cost effective analysis of intra-op cholangiogram ,[object Object],[object Object],[object Object],[object Object],[object Object],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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Massarweh NN, Flum DR, et al. Surgeon Knowledge, Behavior, and Opinions Regarding Intraoperative Cholangiography. JACS 2008;207(6):821-830

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Laparoscopic Ultrasound ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Laparoscopic US as a good alternative to intraoperative cholangiography (IOC)during laparoscopic cholecystectomy:results of prospective study. ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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 ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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: ,[object Object],[object Object],[object Object],[object Object],[object Object],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) Advantages ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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 Making ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Factors influencing approach to the common bile duct 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 + +

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1998, Petelin Laparoscopic CBD Exploration ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Transcystic Approach STUDY N SUCCESS (%) FERZLI, 1991 13 100 SAGES, 1994 187 95 PHILLIPS, 1994 111 91 DePAULA, 1994 102 84 BERTHOU, 1994 78 67 McGRATH, 1994 44 93 DION, 1994 18 94 STOKER, 1995 33 94

Complications of Lap. CBD Exploration

Techniques ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Combined Laparoscopy and ERCP ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Ghazal 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 Trends ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Livingstion EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433

Drainage Procedures ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Cost ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Topal 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 Management ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Treatment of difficult bile duct stones: a particularly safe option for octogenarians ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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 of factors that favor stone fragmentation ,[object Object],[object Object],[object Object],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 were Fragmented 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 after endoscopic clearance of CBD stones ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],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.

Conclusion ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],LAP. CHOLE + CBD STONE ERCP skills Availability of equipment Technical skills

What to do? ERCP MRCP Lap CBD LUS Lap Cholangiogram Transcystic CBD Lap Chole

PREOP INTRAOP POSTOP Sono EUS MRCP ERCP Lap transcystic Lap CBD Open CBD ERCP Conclusion

Transcystic Exploration ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Kozarek, Surg Endosc 1995 Nov;9(11):1235-40 ERCP

WHAT TO DO? ERCP lap CBD EUS IOC MRCP Lap US

Choledochotomy ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

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

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