CURRENT TRENDS IN MANAGEMENT OF

CHOLEDOCHOLITHIASIS

S.K. SAHU

MODERATOR –

DR A. SILODIA

INTRODUCTION – CBD stones

Present in 10 – 15 % of cholecystectomy pts

Incidence rises with age, duration of gallstone symptoms

Associated with high rate of complications

Should always be removed

CLASSIFICATION – CBD Stones

By the point of origin1. Primary CBD Stones2. Secondary CBD Stones

By the time of discovery relative to cholecystectomy

1. Retained 2. Recurrent

PRESENTATION – CBD Stones

Biliary colic Jaundice Pale stools Darkening of urine Fever with chills – cholangitis Charcots triad, Reynolds pentad

LABORATORY INVESTIGATIONS

Elevated s. bilirubin,aminotransferase, alkaline phosphatase

May be normal in 1/3 of patients with CBD Stones

DIAGNOSING CBD STONES

USG– decreased sensitivity– retro and intraduodenal stones not visualized

EUS– increased sensitivity

ERCP– added advantage of being therapeutic in distal

stones

DIAGNOSING CBD STONES

MRCP not a therapeutic procedure does not have morbidity and mortality

associated with ERCP may avoid use of unnecessary invasive

procedures

Indications of MRCP

unsuccessful or contraindicated ERCP patient preference for non-invasive imaging patients considered to be at low risk of

having pancreatic or biliary disease; patients where need for therapeutic ERCP is

unlikely with a suspected neoplastic cause for

pancreatic or biliary obstruction

CBD Stone on USG

CBD Stone on EUS

CBD Stone on MRCP

CBD Stone on IOC

MANAGEMENT – CBD Stones

Open cholecystectomy + surgical exploration of the CBD – in the past/ centres where laparoscopy not available

ERCP + Endoscopic Sphincterotomy followed by cholecystectomy – most frequently used

Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in experienced hands

OPEN CBD EXPLORATION

Time tested method

Indicated if1. Stones detected during open

cholecystectomy2. Need for biliary enteric anastamosis3. Endoscopy difficult / risky4. Unsuccessful LCBDE5. Impacted/ multiple / larger stones

OPEN CBD EXPLORATION

Contraindicated in

1. Small CBD <5mm

2. Portal HT

3. Severe periportal inflammation

4. Cholangitis with septic shock

ERCP + ES - Indications

CBD Stones detected prior to cholecystectomy

High risk patients unfit for operation

Severe cholangitis / pancreatitis

CBD Stone on ERCP

ERCP + ES - complications

Pancreatitis(7%) Cholangitis Bleeding (2%) Perforation Abscess, recurrence Duodenobiliary reflux Rarely death

ERCP +ES - Limitations

Operator dependent

Cost & need for 2nd stage – a concern

Positive ERCP in only 34 % of cases

ADJUVANT TECHNIQUES with ERCP +ES

Mechanical lithotripsy

LASER lithotripsy

Electrohydraulic lithotripsy

ESWL

Chemical contact dissolution therapy

ADJUVANT TECHNIQUES - indications

Stones larger than the endoscope

Shape square/ piston shaped / faceted

Tightly packed stones/ hard stones

Intrahepatic stones

Stones proximal to CBD stricture

Laparoscopic CBD Exploration (LCBDE)

Components Laparoscopic cholecystectomy

Intraoperative cholangiography

Exploration if stone detected

LCBDE - Indications

Abnormal intraoperative cholangiogram or sonogram

Scintigraphic / endoscopic / radiographic evidence of bile duct stones

History of biliary pancreatitis

LCBDE - contraindications

Coagulopathy

Local porta pathology

Inability of surgeon to do LCBDE

Unfit patient

LCBDE - Approach

Transcystic

Choledochotomy

Transcystic LCBDE

Preferred approach Easy, more physiological Cystic duct should join CHD laterally or

posteriorly Indicated in small (<6mm), limited no of

stones(<5),absence of CHD stones

Laparoscopic choledochotomy

Used if cystic duct cant be dilated / intrahepatic pathology

Indicated in large (>6mm), more than 5 stones, CHD stones

Spiral course of cystic duct/ medial opening of cystic duct is an indication

LCBDE - advantages

Single admission/ short hospital stay

Reduced morbidity/ mortality

Success rate comparable to ERCP +ES

Failed LCBDE can be converted to open in the same sitting

LCBDE - limitations

Increased operative time / cost

Expertise not commonly available

SUSPECTED CBD Stones

jaundice No jaundice

Severe comorbidity Fit for surg

ERCP+ES

No further action

Lap chole+IOC

Stones

Operative removal

Post op ERCP

FailureThen choledochoduodenostomy

Failure thenRepeat surgery

MRCP

STONES present No stones

Lap choleunfit fit

Chole +ECBDERCP

CONCLUSION

CBD Stones associated in 10 – 15 % pts undergoing cholecystectomy

Advanced endoscopic & laparoscopic techniques have revolutionised management

Treatment depends on resources, technical limitations, surgeons expertise

LCBDE is safe, feasible, single stage management option for CBD stones

THANK YOU