Management of Cbd Stones Final

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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

INCIDENCE y

y

CBD stones are found in 10-15% of patients with cholelithiasis. Incidence increases with age.

INCIDENCE y

y

CBD stones are found in 10-15% of patients with cholelithiasis. Incidence increases with age.

TYPES y

Two

y

1.Primary

y

types -formed -form ed in bile duct(brown pigment)

2.Secondary-form in the gall bladder-migrate through cystic duct-enter the CBD Two

types:a)cholesterol (75%) b)black pigment(25%)

CLINICAL FEATURES y

 Asymptomatic(15-20%)

y

Recurrent

y

Episodic upper abdominal pain and dyspepsia

y

Stone impaction with progressive jaundice

y

bouts of biliary colic accompanied by intermittent jaundice

Cholangitis(CHA RCOT¶S TRIAD,REYNOLD¶S PENT AD)

y

Gall stone pancreatitis

y

Secondary biliary cirrhosis and portal hypertension

LAB INVESTIGATIONS y

y y

y

Serum bilirubin, serum aminotranferases,alkaline phosphatase-elevated in pts with biliary obstructionneither sensitive nor specific for CBD stones. Elevated amylase and lipase-pancreatitis Elevated WBC countcholangitis,pancreatitis,associated cholecystitis LFT can be normal in 1/3rd of patients with CBD stones.

M ANAGEMENT y

Can be considered under 3 clinical circumstances in which patients who may have CBD stones are seen:

y

1.PRIOR TO CHOLECYSTECTOMY

y

2.DURING CHOLECYSTECTOMY

y

3.SOME TIME AFTER CHOLECYSTECTOMY

PREOPER ATIVE y

Diagnosis of duct stones cannot be made based on history ,physical examination and lab investigations alone.

ULTR ASOUND y y y

y y

TR ANSCUT ANEOUS ULTR ASOUND

Gall stones CBD diameter -no dilatation does not mean no stones(50%-no dilatation) -prevalence of of duct stones is higher in pts with with dilated dilated duct(>5mm) duct(>5mm) vs non dilated dilated duct duct (58% (58% vs 1%) 1%) CBD stones-sensitivity 50%(30-90%) limitations:-operator dependant -gaseous distension of upper upper abdominal viscera -obese -following previous surgery

CT SCAN y

Sensitivity-80%

y

Limitations

y

Exposure to radiation

MRCP y

y y

y y

y

y

This

has emerged as the diagnostic alternative to ERCP for  detection and exclusion of cholelithiasis. Sensitivity 95% PPV-95%,NPV-97%-thus useful in avoiding unnecessary diagnostic ERCP.  AVOIDS ERCP IN>50% OF P ATIENTS. Entire biliary tract can be imaged in a single breath-hold of 20 sec Can visualise upto 4th order intrahepatic bile ducts and can detect stones as small as 2mm. Patients with positive MRCP ±Consider for more invasive therapeutic procedures.

MRCP y

LIMIT ATIONS: 1.less resolution 2.obesity decreases quality of  images 3.claustrophobia 4.pts on pacemakers aneurysmal clips

ENDOSCOPIC ULTR ASOUND y y

y

Diagnostic accuracy -95% for CBD stones Compared with ERCP-it is semi invasive,with almost no procedure related complications and negligible failure rate. EUS prior to invasive diagnostic and therapeutic techniques would lower the rate of procedure related complications in patients suspected of having CBD stones.

ERCP y

y y

ERCP(endoscopic retrograde cholangiopancreatography) Diagnostic as well as therapeutic modality Cannulation of ampulla and diagnostic cholangiography is possible in >90% of cases.

y

Sensitivity-90%

y

Specificity-98%

ERCP y

PROCEDURE

y

Sedation

y

Prone

y

Side viewing duodenoscope

y

y

y

position with head turned to side

Curved cannula into papilla of vater(difficult cannulationin duodenal diverticulum,Billroth 2 GJ,Roux en Y GJ) Small amount of contrast-to confirm visualization of  desired duct  Additional contrast-to define entire selected ductal system

ERCP y

CONTR AINDICATIONS TO ERCP

y

Uncooperative

y

Perforated

y

y y y y

patient

viscus

Newly created esophageal,gastric or duodenal anastomosis. RELATIVE

CONTR AINDICATIONS

 Acute pancreatitis(exacerbation) Pancreatic

pseudocyst(infection)

 Allergy to iodinated contrast(anaphylaxis)

ERCP y

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 DIAGNOSTIC

THERAPEUTIC

ERCP

ERCP

MORBIDITY

3%

7%

 ALITY MORT

0.2%

0.5%

ERCP y

COMPLICATIONS:

y

MC

y

complication:Acute Pancreatitis(1% vs 5%)

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

y

Risk

factors

y

How to minimize pancreatitis

y

Prophylaxis-?somatostatin,?IL-10,GTN

ERCP y y y y y y y

y y y

COMPLICATIONS: Bleeding Sepsis Bowel perforations Cholecystitis Cholangitis Cardiopulmonary complicationsarrythmias,hypoventilation,aspiration-leading cause of  death Recurrent stones Papillary stenosis Liver abscess

ERCP y

y

y

DIAGNOSTIC ERCP-found CBD stones-endoscopic sphincterotomy-stones pass spontaneously or after  irrigation of duct-if not passed-stone extraction with balloon catheter or dormia basket(80-90% extraction rate) If stones are larger-use mechanical/electrohydraulic/laser/ESWL /large balloon dilatation for stone extraction. If stone impacted and could not be removed-pass a stent over a guidewire across the stone.

LIMIT ATIONS y

Mechanical

lithotripsy-difficult to crush hard calcified

stones y

y

Intraductal shock wave lithotripsy-by lithotripsy probe under cholangioscope guidance-risk of bile duct injury. ESWL-fluoroscopic or USG guidance-requires multiple sessions.

PERCUT ANEOUS TR ANSHEP ATIC

CHOLANGIOGR APHY y

If ERCP not available

y

If ERCP not possible due to anatomic considerations

y

If ERCP not successful

y

PROCEDURE:

y

Needle into intrahepatic bile ducts through skincholangiogram done-wire insertion-catheter over  wire for external biliary drainage and access to biliary system.

PTC y

PERCUT ANEOUS TR ANSHEP ATIC ROUTE

y

Dormia basket

y

Transhepatic

y

Percutaneous

cholangioscopy and lithotripsy

choledochoscopy through transhepatic route or through T-tube tract.

y

y

 After bile duct clearance is achieved by non operative methods ,cholecystectomy is recommended in younger patients to decrease the risk of future cholecystitis and recurrent biliary colic. In high risk or elderly patients perform cholecystectomy as needed rather than prophylactically following non operative treatment of  duct stones.

INTR AOPER ATIVE y

y

y

y y

When pts present to the operating room for  cholecystectomy-3 situations can exist 1.Pts have CBD stones confirmed by preoperative studies(ERCP,MRCP,EUS) 2.Pts suspected to have CBD stones by clinical presentation,lab values,usg abdomen 3.No suspicion of CBD stones. 10-15% of patients undergoing laparoscopic cholecystectomy harbor CBD stones,only 15% go on to develop symptoms due to retained stones.

INDICATIONS FOR EXPLOR ATION OF CBD Madden provided good indicators for cholangiography or  exploration of the duct in stone disease. R ecent or present jaundice (cholangiography) Dilatation of the common bile duct (7 mm ultrasonographically or 10 mm at direct visualization) (cholangiography) Multiple stones in the gallbladder together with a large cystic duct (cholangiography)  Aspiration of murky bile from the duct (cholangiography) Presence of a palpable stone (exploration) R oentgenographic visualization of a stone (exploration) When in doubt, explore!  













INTR AOPER ATIVE CHOLANGIOGR APHY y

Most

commonly used method to detect CBD stones during surgery.

y

PROCEDURE

y

Place

y

The

14G catheter into the cystic duct transabdominally 3 cm medial to the midclavicular  port and inject dye and inspect on fluoroscope. need for routine IOC is a matter of debate.

INTR AOPER ATIVE ULTR ASOUND ADVANTAGES

LIMITATIONS

VERY SENSITIVE TEST AND EQUIVALENT TO INTR AOPER ATIVE CHOLANGIOGR AM

HIGH COST OF EQUIPMENT

NO RISK OF CBD INJURY

NEED FOR EXPERTISE

WILL NOT CAUSE FALSE POSITIVE RESULTS OWING TO INTRODUCTION OF AIR INTO THE BILIARY TREE

LEARNING CURVE

y

y y

Once the presence of bile duct stone has been established at the time of surgery-the treatment options include 1.Open or laparoscopic bile duct exploration 2.Post cholecystectomy non operative techniques like ERCP or PTC.

OPEN BILE DUCT EXPLOR ATION y y

y

CBD opened in longitudinal direction Bile duct is cleared of stones by using saline irrigation,fogarty balloon,stone forceps(Ex:DesJardin forceps) and scoops(Ex:Semm scoop) placed into the biliary tract through the opening. Choledhocoscope is also used for stone removal under direct vision and also inspect the biliary tract for any other pathology.

LAP AROSCOPIC COMMON BILE DUCT EXPLOR ATION(LCBDE) y

Techniques

of laparoscopic ductal stone clearance

include y

1.Transcystic duct extraction

y

2.Direct supraduodenal CBD exploration

y

3.Laparoendoscopic approach

TR ANSCYSTIC

DUCT

EXTR ACTION y

Indicated for small floating stones upto 7mm .

y

Two

y

1.the choledochoscopic visually guided method

y

commonly used techniques

2.the radiologically guided wire basket trawling technique.

TR ANSCYSTIC

DUCT

EXTR ACTION y y y y y y y y y

y y y y

Cholangiogram Guidewire into cystic duct Mechanical or pneumatic dilator over wire Choledochoscope insertion Stone extraction Completion cystic duct cholangiogram Ligation of cystic duct Cholecystectomy  Any doubt about residual fragments-insert cystic duct drainage cannula Post op cholangiogram 24hrs after surgery If normal-cannula capped Pt discharged on 3rd pod Cannula removed 10-14 days later.

DIRECT SUPR ADUODENAL CBD EXPLOR ATION y

y y y

y

y y y y

Indicated for large >7mm and occluding stones,cystic duct diameter less than 4mm,cystic duct entrance either posterior  or distal. PROCEDURE

Choledochotomy-1cm or size of largest stone Irrigation of CBD to flush out small stones and sludge facilitated by iv glucagon administration. Stone extraction with basket or choledhoscopic aided extraction. Completion cholangiogram Biliary drainage through T-tube/cystic duct drainage cannula Primary closure of choledochotomy ±decreased hospital stay  Alternative to T-tube ,a stent can be placed in anterograde fashion .

CYSTIC DUCT DRAINAGE

T-TUBE

CANNULA

POST

OP CHOLANGIOGR AM-1ST

7TH POD

POD

CANNULA REMOVAL-7TH POD

2 WEEKS

 ALTERNATIVES TO LAP AROSCOPIC OR OPEN CBD EXPLOR ATION y

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.

CBD STONES AFTER CHOLECYSTECTOMY y

TWO TYPES

y

1.Retained stones-<2yrs after operation

y

2.Recurrent stones->2yrs after operation

RET AINED

STONES

y

Non surgical methods for removal of retained stones

y

1.Flushing

y

2.Dissolution

y

y y

3.Percutaneous stone extraction via a T-tube tract(BURHENNE TECHNIQUE) 4.endoscopic sphincterotomy and stone extraction If above methods fail-surgical biliary drainage procedures.

RECURRENT y

STONES

Endoscopic sphincterotomy and stone extraction is the first line of treatment and surgery (open or  laparoscopic)is reserved if this approach fails.

SURGICAL BILIARY DR AINAGE PROCEDURES y

INDICATIONS

y

1.Multiple stones

y

2.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.

SURGICAL DR AINAGE PROCEDURES y

1.TR ANS DUODENAL SPHINCTEROTOMY

y

2.CHOLEDOCHOD UODENOSTOMY

y

 A)SIDE TO SIDE

y

B)END TO SIDE

y

3.CHOLEDOCHOJEJUNOSTOMYS

TR ANSDUODENAL

SPHINCTEROPLASTY INDICATIONS:

1.Impacted ampullary stone 2.Papillary stenosis 3.Multiple stones,particularly in prescence of non dilated bile duct PROCEDURE

- 2nd portion duodenum - 11 o¶clock incision - ³Cut and sew´ - Pancreatic duct @ 3 to 4 o¶clock -Preserve duodenal lumen -COMPLICATIONS  Pancreatitis: - Extensive manipulation - Electrocautery - Accidental suturing of  pancreatic duct orifice

CHOLEDOCHODUODENOSTOMY y

INDICATIONS

y

1.Recurrent stones requiring repeated interventions

y

2.Impacted or giant stones

y

3.Ampullary stenosis

y

4.Funnel syndrome-distal bile duct stenosis with bile duct stones.

CHOLEDOCHODUODENOSTOMY y y y y

y y y y

y

TYPES:

1.SIDE TO SIDE 2.END TO SIDE CBD diameter of atleast 12mm to create wide stoma which ensures adequate drainage and prevents stenosis. COMPLICATIONS 1.Cholangitis 2.Stenosis of stoma 3.Medical complications-pulmonary embolism,myocardial infarction 4.SUMP syndrome.

CHOEDOCHOJEJUNOSTOMY y

y y

Either with a loop of jejunum or using a configuration.

Roux-en-Y

CDD vs CDJ CHOLEDOCHODUODENOSTOMY is preferred over  CHOLEDOCHOJEJ UNOSTOMY because both procedures have similar outcomes but it is easier to perform CDD than CDJ.CDJ also allows for easy endoscopic interventions if needed in future.

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