Management of CBD stonesManagement of CBD stonesin 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, ErodeEC member, IAGES South ZoneEC member, IAGES South Zone

Chairman Elect, ASI TN & P ChapterChairman Elect, ASI TN & P ChapterExaminer for MRCS (RCS of Edinburgh)Examiner for MRCS (RCS of Edinburgh)

FIAGES@ Jaipur 2016

10% of Patients with Gall stones have associated CBD stones.

CBD stones can have deadly CBD stones can have deadly consequences…consequences…

Cholangitis & SepticemiaCholangitis & Septicemia

Gall Stone PancreatitisGall Stone Pancreatitis

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

22

Biochemical DiagnosisBiochemical DiagnosisPPredicting factorsredicting factors

Liver function testsLiver function tests Bilirubin >3gmBilirubin >3gm Alkaline phosphataseAlkaline phosphatase

Transaminases: SGOT/SGPTTransaminases: SGOT/SGPTGamma GTGamma GT

Kook P et alDo 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

Radiological DiagnosisRadiological Diagnosis

US abdomenUS abdomenCT abdomenCT abdomenMRCPMRCPEUSEUSERCPERCP

33

1. US abdomen1. US abdomen

Non InvasiveDiagnostic

Dilated CBD: >6mm

Low sensitivity

Normal Ultrasound can not exclude CBD stone……

InvasiveDiagnostic

Sensitive testBut…Operator DependentAvailability?

2. Endoscopic US2. Endoscopic US

3. CT abdomen3. CT abdomen

Stomach

Aorta

Spleen

Non InvasiveDiagnostic

Mass

Liver

CBD stone

Non InvasiveDiagnostic

Test of Choice

4. MRCP4. MRCP

Bile duct with stone

Pancreatic duct

5. ERCP For Bile Duct Stones5. ERCP For Bile Duct Stones

TreatmentOf

Choice

InvasiveEssentially Therapeutic

44

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

What will you do prior to Lap chole?

55

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 H/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

What will you do next?

66

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

ERCP TeamERCP Team

•Endoscopy Team

•Radiology Team

•Anaesthetic Team

•Nursing Team

ERCPERCP

ERCP: Diagnostic aspectsERCP: Diagnostic aspectsImpacted 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 Sphincteroplasty

ERCP: Multiple CBD stonesERCP: Multiple CBD stones

•Sphincterotomy•Balloon Sweep•Dormia

About ERCPAbout ERCPA word of Caution!A word of Caution!

Only used as Only used as therapeutictherapeutic modality modalityDuct 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%

77

What is the standard of Care for this lady…

Pre operative DiagnosisPre operative DiagnosisStandard of CareStandard of Care

Pre op ERCP……………Lap cholePre op ERCP……………Lap choleOpen Chole and CBD explorationOpen Chole and CBD exploration

Lap chole…………Post op ERCPLap chole…………Post op ERCPLap chole and Lap CBD explorationLap chole and Lap CBD exploration

ConsiderLocal resources and expertiseMorbidity and cost effectiveness

88

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 : >4mmSize of cystic duct : >4mm Cystic duct entranceCystic duct entrance

HowHow CholangiogramCholangiogram DilatationDilatation CholedochoscopyCholedochoscopy Extraction of stonesExtraction of stones

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

Lap CBD ExplorationLap CBD ExplorationCase SelectionCase SelectionExpertiseExpertiseEquipmentsEquipments

Lap suturing Lap suturing C arm and cholangiogramC arm and cholangiogramStone retrival gadgetsStone retrival gadgets

Dormia/Balloon/ Choangioscope Vs NephroscopeDormia/Balloon/ Choangioscope Vs NephroscopeT tube/StentT tube/StentAdditional monitorsAdditional monitors

Lap CBD Exploration: Lap CBD Exploration: OptionsOptions

•EHL/Laser Lithotripsy•Stent/T tube/Primary suture•Choledocho duodenostomy

Choledocho-duodenostomyCholedocho-duodenostomyIndication:Indication: CBD > 2cm/multiple stones and sludge with stricture lower CBD > 2cm/multiple stones and sludge with stricture lower

end/elderly ptend/elderly ptOperation: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

99

Intra operative diagnosis of Bile duct stonesIntra operative diagnosis of Bile duct stones(During Lap Chole)(During Lap Chole)

Operative CholangiogramOperative CholangiogramRoutineRoutineSelectiveSelective

Suspected CBD stoneSuspected CBD stoneUnclear anatomyUnclear anatomy

Intra operative UltrasoundIntra operative Ultrasound

Management of CBD stonesManagement of CBD stonesAcc to Time of DiagnosisAcc to Time of Diagnosis

Pre-operative Pre-operative Intra- operativeIntra- operativePost -operativePost -operative

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

POST - OPERATIVE DIAGNOSISPOST - OPERATIVE DIAGNOSIS(Minus GB)(Minus GB)

ERCPERCPMRCPMRCPT tube CholangiogramT tube Cholangiogram

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

MRCP1010

MRCP

Non InvasiveDiagnostic

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/M presented with severe abdominal and back pain for 3 days. Serum amylaseWas 2016 units. US abdomen showed multiple small gall stones and dilated CBDAnd enlarged pancreas. In view of unabated pain, fever, and jaundice, the patientUnderwent ERCP.

1111

Severe Biliary PancreatitisSevere Biliary PancreatitisRole of Early ERCPRole of Early ERCP

Neoptolemos et alLancet 2: 976-983, 1988Fan et alN Engl J Med 328: 228-232, 1993

•Less morbidity•Shorter hospital stay•Trend towards lower mortality?

Recent Advances…Recent Advances… LithotripsyLithotripsy

MechanicalMechanical Electro hydraulicElectro hydraulic LaserLaser

CholedochoscopyCholedochoscopy Spy GlassSpy Glass

Rendezvous techniqueRendezvous technique Bioluminence CholangiogramBioluminence Cholangiogram

Advances in ERCPAdvances in ERCPMother & Baby CholangioscopyMother & Baby Cholangioscopy

Spyglass choledochoscopyAdvances in ERCPAdvances in ERCP

Novel way of treating difficult bile duct stones…

ConclusionConclusionMinimal Access-Maximum SuccessMinimal Access-Maximum Success

MRCP is the Test of Choice MRCP is the Test of Choice ERCP is the Treatment of ChoiceERCP is the Treatment of ChoiceLap CBD exploration requires adequate Lap CBD exploration requires adequate

training and appropriate equipmentstraining and appropriate equipmentsBile ducts stones need special attentionBile ducts stones need special attention