Management of Cbd Stones Final

8/8/2019 Management of Cbd Stones Final

1/64

BY SURGERY UNIT II

PROFESSOR:DR.K.VENKATESH

ASST PROFESSORS:DR.PURNAIAH

DR.N.V.N. REDDY

DR.GEETA

POST GRADUATES:DR SYAM BABU

DR .K.RADHA KRISHNA

DR.KALYAN


2/64

INCIDENCEy CBD stones are found in 10-15% of patients with

cholelithiasis.

y Incidence increases with age.


3/64

TYPESy Two types

y 1.Primary -formed in bile duct(brown pigment)

y 2.Secondary-form in the gall bladder-migratethrough cystic duct-enter the CBD

Two types:a)cholesterol (75%)

b)black pigment(25%)


4/64

CLINICAL FEATURESyAsymptomatic(15-20%)

y Recurrent bouts of biliary colic accompanied by

intermittent jaundicey Episodic upper abdominal pain and dyspepsia

y Stone impaction with progressive jaundice

y Cholangitis(CHARCOTS TRIAD,REYNOLDS

PENTAD)

y Gall stone pancreatitis

y Secondary biliary cirrhosis and portal hypertension


5/64

LAB INVESTIGATIONSy Serum bilirubin, serum aminotranferases,alkaline

phosphatase-elevated in pts with biliary obstruction-

neither sensitive nor specific for CBD stones.y Elevated amylase and lipase-pancreatitis

y Elevated WBC count-

cholangitis,pancreatitis,associated cholecystitis

y LFT can be normal in 1/3rd of patients with CBDstones.


6/64

MANAGEMENTy Can be considered under 3 clinical circumstances in

which patients who may have CBD stones are seen:

y 1.PRIORTO CHOLECYSTECTOMYy 2.DURING CHOLECYSTECTOMY

y 3.SOME TIME AFTER CHOLECYSTECTOMY


7/64

PREOPERATIVEy Diagnosis of duct stones cannot be made based on

history ,physical examination and lab investigations

alone.


8/64

ULTRASOUNDy TRANSCUTANEOUS ULTRASOUND

y Gall stones

y CBD diameter -no dilatation does not mean no

stones(50%-no dilatation)-prevalence of duct stones is higher in ptswith dilated duct(>5mm) vs non dilatedduct (58% vs 1%)

y CBD stones-sensitivity 50%(30-90%)

y limitations:-operator dependant

-gaseous distension of upper abdominal viscera

-obese

-following previous surgery


9/64


10/64

CT SCANy Sensitivity-80%

y Limitations

y Exposure to radiation


11/64

MRCPy This has emerged as the diagnostic alternative to ERCP for

detection and exclusion of cholelithiasis.

y

Sensitivity 95%y PPV-95%,NPV-97%-thus useful in avoiding unnecessary

diagnostic ERCP.

y AVOIDS ERCP IN>50% OF PATIENTS.

y Entire biliary tract can be imaged in a single breath-hold of 20sec

y Can visualise upto 4th order intrahepatic bile ducts and candetect stones as small as 2mm.

y Patients with positive MRCP Consider for more invasivetherapeutic procedures.


12/64

MRCP

y LIMITATIONS: 1.less resolution

2.obesity decreases quality ofimages

3.claustrophobia

4.pts on pacemakers

aneurysmal clips


13/64


14/64

ENDOSCOPIC ULTRASOUND

y Diagnostic accuracy -95% for CBD stones

y Compared with ERCP-it is semi invasive,with almostno procedure related complications and negligible

failure rate.

y EUS prior to invasive diagnostic and therapeutic

techniques would lower the rate of procedure relatedcomplications in patients suspected of having CBD

stones.


15/64


16/64

ERCPy ERCP(endoscopic retrograde

cholangiopancreatography)

yDiagnostic as well as therapeutic modality

y Cannulation of ampulla and diagnostic

cholangiography is possible in >90% of cases.

y Sensitivity-90%

y Specificity-98%


17/64

ERCPy PROCEDURE

y Sedation

yProne position with head turned to side

y Side viewing duodenoscope

y Curved cannula into papilla of vater(difficult cannulation-

in duodenal diverticulum,Billroth 2 GJ,Roux en Y GJ)

ySmall amount of contrast-to confirm visualization ofdesired duct

y Additional contrast-to define entire selected ductal

system


18/64


19/64


20/64


21/64

ERCPy CONTRAINDICATIONS TO ERCP

y Uncooperative patient

y Perforated viscusy Newly created esophageal,gastric or duodenal

anastomosis.

y RELATIVE CONTRAINDICATIONS

yAcute pancreatitis(exacerbation)

y Pancreatic pseudocyst(infection)

yAllergy to iodinated contrast(anaphylaxis)


22/64

ERCPy COMPLICATIONS:found to relate to five risk factors:

1.sphincter of oddi dysfunction

2.prescence of cirrhosis

3.difficulty in cannulating bile duct

4.use of precut sphincterotomy to access to bile

duct

5.combined percutaneous endoscopic procedure

DIAGNOSTICERCP

THERAPEUTICERCP

MORBIDITY 3% 7%

MORTALITY 0.2% 0.5%


23/64

ERCPy COMPLICATIONS:

y MC complication:Acute Pancreatitis(1% vs 5%)

y Definition :serum amylase>3times ,24 hrs afterERCP ,requiring at least 2 days hospital stay.

y Risk factors

y How to minimize pancreatitis

y Prophylaxis-?somatostatin,?IL-10,GTN


24/64

ERCPy COMPLICATIONS:

y Bleeding

y Sepsis

y Bowel perforationsy Cholecystitis

y Cholangitis

y Cardiopulmonary complications-arrythmias,hypoventilation,aspiration-leading cause ofdeath

y Recurrent stones

y Papillary stenosis

y Liver abscess


25/64

ERCPy DIAGNOSTIC ERCP-found CBD stones-endoscopic

sphincterotomy-stones pass spontaneously or after

irrigation of duct-if not passed-stone extraction withballoon catheter or dormia basket(80-90% extraction

rate)

y If stones are larger-use

mechanical/electrohydraulic/laser/ESWL /largeballoon dilatation for stone extraction.

y If stone impacted and could not be removed-pass a

stent over a guidewire across the stone.


26/64


27/64


28/64


29/64

LIMITATIONSy Mechanical lithotripsy-difficult to crush hard calcified

stones

yIntraductal shock wave lithotripsy-by lithotripsy probeunder cholangioscope guidance-risk of bile duct

injury.

y ESWL-fluoroscopic orUSG guidance-requires

multiple sessions.


30/64

PERCUTANEOUS TRANSHEPATIC

CHOLANGIOGRAPHYy If ERCP not available

y If ERCP not possible due to anatomic considerations

y If ERCP not successfuly PROCEDURE:

y Needle into intrahepatic bile ducts through skin-

cholangiogram done-wire insertion-catheter over

wire for external biliary drainage and access tobiliary system.


31/64

PTCy PERCUTANEOUS TRANSHEPATIC ROUTE

y Dormia basket

y Transhepatic cholangioscopy and lithotripsyy Percutaneous choledochoscopy through

transhepatic route or through T-tube tract.


32/64

yAfter bile duct clearance is achieved by non

operative methods ,cholecystectomy is

recommended in younger patients to decrease therisk of future cholecystitis and recurrent biliary colic.

y In high risk or elderly patients perform

cholecystectomy as needed rather than

prophylactically following non operative treatment of

duct stones.


33/64


34/64

INTRAOPERATIVEy When pts present to the operating room for

cholecystectomy-3 situations can exist

y

1.Pts have CBD stones confirmed bypreoperative studies(ERCP,MRCP,EUS)

y 2.Pts suspected to have CBD stones by clinical

presentation,lab values,usg abdomen

y 3.No suspicion of CBD stones.y 10-15% of patients undergoing laparoscopic

cholecystectomy harbor CBD stones,only 15% go on

to develop symptoms due to retained stones.


35/64

INDICAT

IONS FOR

EXP

LORAT

ION OF CBDMadden provided good indicators for cholangiography or

exploration of the duct in stone disease.

Recent or present jaundice (cholangiography)

Dilatation of the common bile duct (7 mmultrasonographically or 10 mm at direct visualization)(cholangiography)

Multiple stones in the gallbladder together with a largecystic duct (cholangiography)

Aspiration of murky bile from the duct (cholangiography)

Presence of a palpable stone (exploration)

Roentgenographic visualization of a stone (exploration)

When in doubt, explore!


36/64

INTRAOPERATIVE

CHOLANGIOGRAPHYy Most commonly used method to detect CBD stones

during surgery.

y

PROCEDUREy Place 14G catheter into the cystic duct

transabdominally 3 cm medial to the midclavicular

port and inject dye and inspect on fluoroscope.

y The need for routine IOC is a matter of debate.


37/64


38/64

INTRAOPERATIVE

ULTRASOUNDADVANTAGES LIMITATIONS

VERYSENSITIVE TESTANDEQUIVALENTTO INTRAOPERATIVE

CHOLANGIOGRAM

HIGH COST OF EQUIPMENT

NO RISK OF CBD INJURY NEED FOR EXPERTISE

WILLNOT CAUSE FALSE POSITIVE

RESULTS OWING TO

INTRODUCTION OF AIR INTO THE

BILIARYTREE

LEARNING CURVE


39/64

y Once the presence of bile duct stone has been

established at the time of surgery-the treatment

options include

y 1.Open or laparoscopic bile duct exploration

y 2.Post cholecystectomy non operative techniques

like ERCP orPTC.


40/64

OPEN BILE DUCT

EXPLORATIONy CBD opened in longitudinal direction

y Bile duct is cleared of stones by using saline

irrigation,fogarty balloon,stone forceps(Ex:DesJardinforceps) and scoops(Ex:Semm scoop) placed into

the biliary tract through the opening.

y Choledhocoscope is also used for stone removal

under direct vision and also inspect the biliary tractfor any other pathology.


41/64

LAPAROSCOPIC COMMON BILE

DUCT EXPLORATION(LCBDE)y Techniques of laparoscopic ductal stone clearance

include

y

1.Transcystic duct extractiony 2.Direct supraduodenal CBD exploration

y 3.Laparoendoscopic approach


42/64

TRANSCYSTIC DUCT

EXTRACTIONy Indicated for small floating stones upto 7mm .

y Two commonly used techniques

y 1.the choledochoscopic visually guided methody 2.the radiologically guided wire basket trawling

technique.


43/64

TRANSCYSTIC DUCT

EXTRACTIONy Cholangiogram

y Guidewire into cystic duct

y Mechanical or pneumatic dilator over wire

y Choledochoscope insertion

y Stone extraction

y Completion cystic duct cholangiogram

y Ligation of cystic duct

y Cholecystectomy

y Any doubt about residual fragments-insert cystic duct drainage

cannulay Post op cholangiogram 24hrs after surgery

y If normal-cannula capped

y Pt discharged on 3rd pod

y Cannula removed 10-14 days later.


44/64


45/64


46/64


47/64

DIRECT SUPRADUODENAL

CBD EXPLORATIONy Indicated for large >7mm and occluding stones,cystic duct

diameter less than 4mm,cystic duct entrance either posterioror distal.

y PROCEDURE

y Choledochotomy-1cm or size of largest stone

y Irrigation of CBD to flush out small stones and sludgefacilitated by iv glucagon administration.

y Stone extraction with basket or choledhoscopic aidedextraction.

y Completion cholangiogramy Biliary drainage through T-tube/cystic duct drainage cannula

y Primary closure of choledochotomy decreased hospital stay

y Alternative to T-tube ,a stent can be placed in anterogradefashion .


48/64


49/64

CYSTIC DUCT DRAINAGE

CANNULA

T-TUBE

POST OP CHOLANGIOGRAM-1ST

POD

7TH POD

CANNULAREMOVAL-7TH POD 2 WEEKS


50/64

ALTERNATIVES TO LAPAROSCOPIC

OR OPEN CBD EXPLORATIONy Transcystic stent placement over a wire antegrade

through sphincter of oddi at the time of

cholecystectomy.

y Intraoperative ERCP and stent placement.

y Intraoperative vs postoperative ERCP.

C S O S


51/64

CBD STONES AFTER

CHOLECYSTECTOMY

y TWO TYPES

y 1.Retained stones-2yrs after operation


52/64

RETAINED STONESy Non surgical methods for removal of retained stones

y 1.Flushing

y 2.Dissolutiony 3.Percutaneous stone extraction via a T-tube

tract(BURHENNE TECHNIQUE)

y 4.endoscopic sphincterotomy and stone extraction

y If above methods fail-surgical biliary drainageprocedures.


53/64


54/64

RECURRENT STONESy Endoscopic sphincterotomy and stone extraction is

the first line of treatment and surgery (open or

laparoscopic)is reserved if this approach fails.


55/64

SURGICAL BILIARY

DRAINAGE PROCEDURESy INDICATIONS

y 1.Multiple stones

y2.Incomplete removal of all stones

y 3.Impacted,irremovable distal bile duct stones

y 4.Markedly dilated CBD

y 5.Distal CBD obstruction fron tumor or stricture

y 6.Reoccurance after previous CBD exploration.


56/64

SURGICAL DRAINAGE

PROCEDURESy 1.TRANS DUODENAL SPHINCTEROTOMY

y 2.CHOLEDOCHODUODENOSTOMY

yA)SIDE TO SIDE

y B)END TO SIDE

y 3.CHOLEDOCHOJEJUNOSTOMYS


57/64

TRANSDUODENAL

SPHINCTEROPLASTYINDICATIONS:

1.Impacted ampullary stone

2.Papillary stenosis

3.Multiple stones,particularly in prescence of non dilated bile duct

PROCEDURE

- 2nd portion duodenum

- 11 oclock incision

- Cut and sew

- Pancreatic duct @ 3 to 4

oclock

-Preserve duodenal lumen-COMPLICATIONS

Pancreatitis:

- Extensive manipulation

- Electrocautery

- Accidental suturing of

pancreatic duct orifice


58/64


59/64


60/64

CHOLEDOCHODUODENOSTOMYy TYPES:

y 1.SIDE TO SIDE

y 2.END TO SIDE

y CBD diameter of atleast 12mm to create wide stomawhich ensures adequate drainage and prevents stenosis.

y COMPLICATIONS

y 1.Cholangitis

y 2.Stenosis of stomay 3.Medical complications-pulmonary embolism,myocardial

infarction

y 4.SUMP syndrome.


61/64


62/64

CHOEDOCHOJEJUNOSTOMYy Either with a loop of jejunum or using a Roux-en-Y

configuration.

y

CDD vs CDJy CHOLEDOCHODUODENOSTOMY is preferred over

CHOLEDOCHOJEJUNOSTOMY because both

procedures have similar outcomes but it is easier to

perform CDD than CDJ.CDJ also allows for easyendoscopic interventions if needed in future.


63/64


64/64

CONCLUSIONy Multidisciplinary approach to CBD stones

y Multiple treatment options are available so that

treatment can be tailored to fit each individualsituation

y Laparoscopic CBD exploration is safe and

carries low morbidity and mortality rate.

y Surgeon experience determines: Lap vs Open approach

Type of drainage procedure if necessary

Management of Cbd Stones Final

Documents

Transcript of Management of Cbd Stones Final