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Management of CBD stonesManagement of CBD stones
in the Era of Laparoscopyin the Era of Laparoscopy
Dr.S.EaswaramoorthyDr....
10% of Patients with Gall stones have associated CBD stones.
CBD stones can have deadlyCBD stones can have deadly
consequences…consequences…
 Cholangitis & SepticemiaCholangitis & Se...
CBD Stone: PresentationCBD Stone: Presentation
 CholangitisCholangitis
 Charcot’s triadCharcot’s triad
 Intermittent pa...
22
Biochemical DiagnosisBiochemical Diagnosis
PPredicting factorsredicting factors
Liver function testsLiver function tests
B...
Radiological DiagnosisRadiological Diagnosis
 US abdomenUS abdomen
 CT abdomenCT abdomen
 MRCPMRCP
 EUSEUS
 ERCPERCP
33
1. US abdomen1. US abdomen
Non Invasive
Diagnostic
Dilated CBD: >6mm
Low sensitivity
Normal Ultrasound can not exclude CBD...
Invasive
Diagnostic
Sensitive test
But…
Operator Dependent
Availability?
2. Endoscopic US2. Endoscopic US
3. CT abdomen3. CT abdomen
Stomach
Aorta
Spleen
Non Invasive
Diagnostic
Mass
Liver
CBD stone
Non Invasive
Diagnostic
Test of Choice
4. MRCP4. MRCP
Bile duct with stone
Pancreatic duct
5. ERCP For Bile Duct Stones5. ERCP For Bile Duct Stones
Treatment
Of
Choice
Invasive
Essentially Therapeutic
44
Pre operative risk assessmentPre operative risk assessment
 High risk (>50%):High risk (>50%): ERCPERCP
 Clinical Jaundi...
What will you do prior to Lap chole?
55
Pre operative risk assessmentPre operative risk assessment
 High risk (>50%):High risk (>50%): ERCPERCP
 Clinical Jaundi...
What will you do next?
66
Pre operative risk assessmentPre operative risk assessment
 High risk (>50%):High risk (>50%): ERCPERCP
 Clinical Jaundi...
ERCP TeamERCP Team
•Endoscopy Team
•Radiology Team
•Anaesthetic Team
•Nursing Team
ERCPERCP
ERCP: Diagnostic aspectsERCP: Diagnostic aspects
Impacted stone
Pouring out Pus
Road Map
Side Viewing Scope & AccessoriesSide Viewing Scope & Accessories
Balloon, Basket & Biopsy forceps…
ERCP : Therapeutic AdvantageERCP : Therapeutic Advantage
Sphincterotomy
Balloon Sweep
Lithotripsy
Selective Cannulation Sp...
ERCP: Multiple CBD stonesERCP: Multiple CBD stones
•Sphincterotomy
•Balloon Sweep
•Dormia
About ERCPAbout ERCP
A word of Caution!A word of Caution!
 Only used asOnly used as therapeutictherapeutic modalitymodali...
77
What is the standard of Care for this lady…
Pre operative DiagnosisPre operative Diagnosis
Standard of CareStandard of Care
 Pre op ERCP……………Lap cholePre op ERCP…………...
88
Laparoscopic management of CBD stonesLaparoscopic management of CBD stones
1. Transcystic approach1. Transcystic approach
...
2. Lap CBD Exploration2. Lap CBD Exploration
•Exposure of CBD
•Vertical Choledochotomy
•Squeeze technique
•Flushing Techni...
Lap CBD ExplorationLap CBD Exploration
 Case SelectionCase Selection
 ExpertiseExpertise
 EquipmentsEquipments
Lap sut...
Lap CBD Exploration:Lap CBD Exploration: OptionsOptions
•EHL/Laser Lithotripsy
•Stent/T tube/Primary suture
•Choledocho du...
Choledocho-duodenostomyCholedocho-duodenostomy
Indication:Indication:
 CBD > 2cm/multiple stones and sludge with strictur...
99
Intra operative diagnosis of Bile duct stonesIntra operative diagnosis of Bile duct stones
(During Lap Chole)(During Lap C...
Management of CBD stonesManagement of CBD stones
Acc to Time of DiagnosisAcc to Time of Diagnosis
Pre-operativePre-operat...
Standard of CareStandard of Care
 Lap chole/Post op ERCPLap chole/Post op ERCP
 Lap chole/Lap CBD explorationLap chole/L...
POST - OPERATIVE DIAGNOSISPOST - OPERATIVE DIAGNOSIS
(Minus GB)(Minus GB)
 ERCPERCP
 MRCPMRCP
 T tube CholangiogramT tu...
60/M with 4 months history of fever and abdominal pain on and off.
H/o cholecystectomy 10 years ago.
He also gave history ...
MRCP
1010
MRCP
Non Invasive
Diagnostic
CBD
Stone
Test
Of
Choice
ERCP : Your diagnosis?ERCP : Your diagnosis?
A case of Gall Stone PancreatitisA case of Gall Stone Pancreatitis
Needle Knife Sphincterotomy
Impacted stone at Ampula
34...
1111
Severe Biliary PancreatitisSevere Biliary Pancreatitis
Role of Early ERCPRole of Early ERCP
Neoptolemos et al
Lancet 2: 97...
Recent Advances…Recent Advances…
 LithotripsyLithotripsy
 MechanicalMechanical
 Electro hydraulicElectro hydraulic
 La...
Advances in ERCPAdvances in ERCP
Mother & Baby CholangioscopyMother & Baby Cholangioscopy
Spyglass choledochoscopy
Advances in ERCPAdvances in ERCP
Novel way of treating difficult bile duct stones…
ConclusionConclusion
Minimal Access-Maximum SuccessMinimal Access-Maximum Success
 MRCP is the Test of ChoiceMRCP is the ...
Management of bile duct stones
Management of bile duct stones
Management of bile duct stones
Management of bile duct stones
Management of bile duct stones
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Management of bile duct stones

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role of ERCP and laparoscopy in managing cbd stones

Publicado en: Salud y medicina
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Management of bile duct stones

  1. 1. Management of CBD stonesManagement of CBD stones in the Era of Laparoscopyin the Era of Laparoscopy Dr.S.EaswaramoorthyDr.S.Easwaramoorthy MS FRCS (Eng), FRCS (Edin), FRCS (Glasgow)MS FRCS (Eng), FRCS (Edin), FRCS (Glasgow) Consultant Surgeon, Lotus Hospital, ErodeConsultant Surgeon, Lotus Hospital, Erode EC member, IAGES South ZoneEC member, IAGES South Zone Chairman Elect, ASI TN & P ChapterChairman Elect, ASI TN & P Chapter Examiner for MRCS (RCS of Edinburgh)Examiner for MRCS (RCS of Edinburgh) FIAGES@ Jaipur 2016
  2. 2. 10% of Patients with Gall stones have associated CBD stones.
  3. 3. CBD stones can have deadlyCBD stones can have deadly consequences…consequences…  Cholangitis & SepticemiaCholangitis & Septicemia  Gall Stone PancreatitisGall Stone Pancreatitis
  4. 4. CBD Stone: PresentationCBD Stone: Presentation  CholangitisCholangitis  Charcot’s triadCharcot’s triad  Intermittent painIntermittent pain  Intermittent feverIntermittent fever  Intermittent jaundiceIntermittent jaundice  Reynold’s PentadReynold’s Pentad  HypotentionHypotention  ConfusionConfusion  Obstructive JaundiceObstructive Jaundice  PancreatitisPancreatitis  AsymptomaticAsymptomatic
  5. 5. 22
  6. 6. Biochemical DiagnosisBiochemical Diagnosis PPredicting factorsredicting factors Liver function testsLiver function tests Bilirubin >3gmBilirubin >3gm Alkaline phosphataseAlkaline phosphatase Transaminases: SGOT/SGPTTransaminases: SGOT/SGPT Gamma GTGamma GT Kook P et al Do Pre operative indicators predict the presence of CBD stones during lap chole? Am J Surg, 495-499, 1996 Normal Liver profile does not exclude CBD stones
  7. 7. Radiological DiagnosisRadiological Diagnosis  US abdomenUS abdomen  CT abdomenCT abdomen  MRCPMRCP  EUSEUS  ERCPERCP
  8. 8. 33
  9. 9. 1. US abdomen1. US abdomen Non Invasive Diagnostic Dilated CBD: >6mm Low sensitivity Normal Ultrasound can not exclude CBD stone……
  10. 10. Invasive Diagnostic Sensitive test But… Operator Dependent Availability? 2. Endoscopic US2. Endoscopic US
  11. 11. 3. CT abdomen3. CT abdomen Stomach Aorta Spleen Non Invasive Diagnostic Mass Liver CBD stone
  12. 12. Non Invasive Diagnostic Test of Choice 4. MRCP4. MRCP Bile duct with stone Pancreatic duct
  13. 13. 5. ERCP For Bile Duct Stones5. ERCP For Bile Duct Stones Treatment Of Choice Invasive Essentially Therapeutic
  14. 14. 44
  15. 15. Pre operative risk assessmentPre operative risk assessment  High risk (>50%):High risk (>50%): ERCPERCP  Clinical Jaundice, CholangitisClinical Jaundice, Cholangitis  Bilirubin > 3mgmBilirubin > 3mgm  CBD > 6mm, Stone in CBDCBD > 6mm, Stone in CBD  Moderate risk ( 10-50%):Moderate risk ( 10-50%): MRCP/EUS/ICMRCP/EUS/IC  H/O of Jaundice or pancreatitisH/O of Jaundice or pancreatitis  Multiple small stones in GBMultiple small stones in GB  Raised Al.Phosphatase and bilirubinRaised Al.Phosphatase and bilirubin  Low risk ( < 5%):Low risk ( < 5%):  Normal Liver profileNormal Liver profile  US: Normal CBD. Large stone in GBUS: Normal CBD. Large stone in GB  No H/O of Jaundice or pancreatitisNo H/O of Jaundice or pancreatitis ASGE Standards of Practice Committee et al 2010
  16. 16. What will you do prior to Lap chole? 55
  17. 17. Pre operative risk assessmentPre operative risk assessment  High risk (>50%):High risk (>50%): ERCPERCP  Clinical Jaundice, CholangitisClinical Jaundice, Cholangitis  Bilirubin > 3mgmBilirubin > 3mgm  CBD > 6mm, Stone in CBDCBD > 6mm, Stone in CBD  Moderate risk ( 10-50%):Moderate risk ( 10-50%): MRCP/EUS/ICMRCP/EUS/IC  H/O of Jaundice orH/O of Jaundice or pancreatitispancreatitis  Multiple small stones in GBMultiple small stones in GB  Raised Al.Phosphatase and bilirubinRaised Al.Phosphatase and bilirubin  Low risk ( < 5%):Low risk ( < 5%):  Normal Liver profileNormal Liver profile  US: Normal CBD. Large stone in GBUS: Normal CBD. Large stone in GB  No H/O of Jaundice or pancreatitisNo H/O of Jaundice or pancreatitis ASGE Standards of Practice Committee et al 2010
  18. 18. What will you do next? 66
  19. 19. Pre operative risk assessmentPre operative risk assessment  High risk (>50%):High risk (>50%): ERCPERCP  Clinical JaundiceClinical Jaundice,, CholangitisCholangitis  Bilirubin > 3mgmBilirubin > 3mgm  CBD > 6mmCBD > 6mm, Stone in CBD, Stone in CBD  Moderate risk ( 10-50%):Moderate risk ( 10-50%): MRCP/EUS/ICMRCP/EUS/IC  H/O of Jaundice or pancreatitisH/O of Jaundice or pancreatitis  Multiple small stones in GBMultiple small stones in GB  Raised Al.Phosphatase and bilirubinRaised Al.Phosphatase and bilirubin  Low risk ( < 5%):Low risk ( < 5%):  Normal Liver profileNormal Liver profile  US: Normal CBD. Large stone in GBUS: Normal CBD. Large stone in GB  No H/O of Jaundice or pancreatitisNo H/O of Jaundice or pancreatitis ASGE Standards of Practice Committee et al 2010
  20. 20. ERCP TeamERCP Team •Endoscopy Team •Radiology Team •Anaesthetic Team •Nursing Team
  21. 21. ERCPERCP
  22. 22. ERCP: Diagnostic aspectsERCP: Diagnostic aspects Impacted stone Pouring out Pus Road Map
  23. 23. Side Viewing Scope & AccessoriesSide Viewing Scope & Accessories Balloon, Basket & Biopsy forceps…
  24. 24. ERCP : Therapeutic AdvantageERCP : Therapeutic Advantage Sphincterotomy Balloon Sweep Lithotripsy Selective Cannulation Sphincteroplasty
  25. 25. ERCP: Multiple CBD stonesERCP: Multiple CBD stones •Sphincterotomy •Balloon Sweep •Dormia
  26. 26. About ERCPAbout ERCP A word of Caution!A word of Caution!  Only used asOnly used as therapeutictherapeutic modalitymodality  Duct Cannulation rate: 95%Duct Cannulation rate: 95%  Duct Clearance rate : 90%Duct Clearance rate : 90%  ComplicationsComplications Pancreatitis: 5%Pancreatitis: 5% Bleeding : 3%Bleeding : 3% Perforation: 1%Perforation: 1%  MortalityMortality: 1%: 1%
  27. 27. 77 What is the standard of Care for this lady…
  28. 28. Pre operative DiagnosisPre operative Diagnosis Standard of CareStandard of Care  Pre op ERCP……………Lap cholePre op ERCP……………Lap chole  Open Chole and CBD explorationOpen Chole and CBD exploration  Lap chole…………Post op ERCPLap chole…………Post op ERCP  Lap chole and Lap CBD explorationLap chole and Lap CBD exploration Consider Local resources and expertise Morbidity and cost effectiveness
  29. 29. 88
  30. 30. Laparoscopic management of CBD stonesLaparoscopic management of CBD stones 1. Transcystic approach1. Transcystic approach  WhenWhen  Size of the stones : smallSize of the stones : small  Size of cystic duct :Size of cystic duct : >4mm>4mm  Cystic duct entranceCystic duct entrance  HowHow  CholangiogramCholangiogram  DilatationDilatation  CholedochoscopyCholedochoscopy  Extraction of stonesExtraction of stones
  31. 31. 2. Lap CBD Exploration2. Lap CBD Exploration •Exposure of CBD •Vertical Choledochotomy •Squeeze technique •Flushing Techniques •Balloon sweep technique •Basket technique •Choledochoscopic technique WhenWhen  Dilated ductDilated duct  Large stonesLarge stones  Also proximal stonesAlso proximal stones
  32. 32. Lap CBD ExplorationLap CBD Exploration  Case SelectionCase Selection  ExpertiseExpertise  EquipmentsEquipments Lap suturingLap suturing C arm and cholangiogramC arm and cholangiogram Stone retrival gadgetsStone retrival gadgets Dormia/Balloon/ Choangioscope Vs NephroscopeDormia/Balloon/ Choangioscope Vs Nephroscope T tube/StentT tube/Stent Additional monitorsAdditional monitors
  33. 33. Lap CBD Exploration:Lap CBD Exploration: OptionsOptions •EHL/Laser Lithotripsy •Stent/T tube/Primary suture •Choledocho duodenostomy
  34. 34. Choledocho-duodenostomyCholedocho-duodenostomy Indication:Indication:  CBD > 2cm/multiple stones and sludge with stricture lowerCBD > 2cm/multiple stones and sludge with stricture lower end/elderly ptend/elderly pt Operation:Operation:  Open Vs LapOpen Vs Lap  Vertical supra-duodenal choledochotomyVertical supra-duodenal choledochotomy  Longitudinal duodenotomy : 1st partLongitudinal duodenotomy : 1st part  Interrupted 3-0 vicrylInterrupted 3-0 vicryl
  35. 35. 99
  36. 36. Intra operative diagnosis of Bile duct stonesIntra operative diagnosis of Bile duct stones (During Lap Chole)(During Lap Chole) Operative CholangiogramOperative Cholangiogram RoutineRoutine SelectiveSelective Suspected CBD stoneSuspected CBD stone Unclear anatomyUnclear anatomy Intra operative UltrasoundIntra operative Ultrasound
  37. 37. Management of CBD stonesManagement of CBD stones Acc to Time of DiagnosisAcc to Time of Diagnosis Pre-operativePre-operative Intra- operativeIntra- operative Post -operativePost -operative
  38. 38. Standard of CareStandard of Care  Lap chole/Post op ERCPLap chole/Post op ERCP  Lap chole/Lap CBD explorationLap chole/Lap CBD exploration  Convert to Open chole and CBD explorationConvert to Open chole and CBD exploration
  39. 39. POST - OPERATIVE DIAGNOSISPOST - OPERATIVE DIAGNOSIS (Minus GB)(Minus GB)  ERCPERCP  MRCPMRCP  T tube CholangiogramT tube Cholangiogram
  40. 40. 60/M with 4 months history of fever and abdominal pain on and off. H/o cholecystectomy 10 years ago. He also gave history Of passing dark urine at least in 2 occasion. Following US , the patient underwent MRCP
  41. 41. MRCP 1010
  42. 42. MRCP Non Invasive Diagnostic CBD Stone Test Of Choice
  43. 43. ERCP : Your diagnosis?ERCP : Your diagnosis?
  44. 44. A case of Gall Stone PancreatitisA case of Gall Stone Pancreatitis Needle Knife Sphincterotomy Impacted stone at Ampula 34/M presented with severe abdominal and back pain for 3 days. Serum amylase Was 2016 units. US abdomen showed multiple small gall stones and dilated CBD And enlarged pancreas. In view of unabated pain, fever, and jaundice, the patient Underwent ERCP.
  45. 45. 1111
  46. 46. Severe Biliary PancreatitisSevere Biliary Pancreatitis Role of Early ERCPRole of Early ERCP Neoptolemos et al Lancet 2: 976-983, 1988 Fan et al N Engl J Med 328: 228-232, 1993 •Less morbidity •Shorter hospital stay •Trend towards lower mortality?
  47. 47. Recent Advances…Recent Advances…  LithotripsyLithotripsy  MechanicalMechanical  Electro hydraulicElectro hydraulic  LaserLaser  CholedochoscopyCholedochoscopy  Spy GlassSpy Glass  Rendezvous techniqueRendezvous technique  Bioluminence CholangiogramBioluminence Cholangiogram
  48. 48. Advances in ERCPAdvances in ERCP Mother & Baby CholangioscopyMother & Baby Cholangioscopy
  49. 49. Spyglass choledochoscopy Advances in ERCPAdvances in ERCP
  50. 50. Novel way of treating difficult bile duct stones…
  51. 51. ConclusionConclusion Minimal Access-Maximum SuccessMinimal Access-Maximum Success  MRCP is the Test of ChoiceMRCP is the Test of Choice  ERCP is the Treatment of ChoiceERCP is the Treatment of Choice  Lap CBD exploration requires adequateLap CBD exploration requires adequate training and appropriate equipmentstraining and appropriate equipments  Bile ducts stones need special attentionBile ducts stones need special attention

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