Endoscopic management of common bile duct

stonesShannon AckerAugust 1, 2011

Gallstones occur in 15% of population

10-50% cause symptoms within 10-20 yrs

10-18% of patients who have cholecystectomy for gallstones have common bile duct (CBD) stones

Natural history of CBD stones is not known, complications appear to be more frequent and severe than with asymptomatic stones

Martin DJ, et al. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database Syst Rev 2006;CD003327.

Evolution of CBDS management

1889 - first surgical exploration of the CBD by Swiss Surgeon Ludwig Courvoisier via incision in the CBD

1960s - Mazzariello, an Argentinean surgeon, introduced non operative instrument extraction of retained CBDS via T-tubes

1970s -Gastroenterologists from Germany and Japan introduced endoscopic sphincterotomy for retained CBDS

Memon MA, et al. Laparoscopic common bile duct exploration: the past, the present, and the future. The Amer J of Surg 2000:179.

Evolution of CBDS management

In the era of open cholecystectomy, intraoperative cholangiography was performed routinely

Surgical CBD stone extraction was the recommended treatment option

Open CBD exploration results in: lower primary treatment failure fewer additional procedures fewer average number of procedures required per

patient lower mortalitywhen compared to ERCP Martin DJ, et al. Surgical versus endoscopic

treatment of bile duct stones. Cochrane Database Syst Rev 2006;CD003327.

Evolution of Cholecystectomy

Laparoscopic cholecystectomy introduced in 1985 by Erich Muhe -Germany

Advantages of laparoscopy: shorter

hospitalizations quicker return to work decreased

complications less postoperative

pain

Kroh M, Chand B. Choledocholithiasis, endoscopic retrograde cholangiopancreatography, and laparoscopic common bile duct exploration. Surg Clin N Am 88(2008)1019-31.

CBDS in the era of laparoscopic cholecystectomy Advances in

endoscopic stone clearance techniques Endoscopic

sphincterotomy Endoscopic

baskets, balloons, lithotripsy devices

Advances in laparoscopy Improved experience

and instrumentation Transcystic stone

removal Laparoscopic

choledochotomy with stone clearance

Transcystic stenting followed by post operative ERCPKroh M, Chand B. Choledocholithiasis, endoscopic retrograde

cholangiopancreatography, and laparoscopic common bile duct exploration. Surg Clin N Am 88(2008)1019-31.

Current Debate

Advantages of Endoscopic Treatment of CBD StonesOptimal for elderly and high risk

patientsPrimary treatment for acute

cholangitis and gallstone pancreatitis

Option as single therapy for common bile duct stones

Acute Cholangitis 82 patients with severe acute cholangitis due

to choledocholithiasis randomly assigned to undergo surgical decompression of the biliary tract or endoscopic biliary drainage

Lai ECS, at al. Endoscopic biliary drainage for severe acute cholangitis. NEJM 1992; 326:24.

Acute Cholangitis Review of 94 pts admitted with acute

cholangitis: 82 had CBD stones, 71 underwent

decompression28 surgically, 43 ES

Endoscopic sphincterotomy (ES) associated with lower 30 day mortality

Of 43 pts undergoing ES23 had gallbladder left in situ; 2 of 23 required

future cholecystectomy

Endoscopic biliary drainage is associated with a significantly reduced mortality and morbidity rate

Lai ECS, at al. Endoscopic biliary drainage for severe acute cholangitis. NEJM 1992; 326:24. Leese T, Neoptolomos JP, Baker AR (1985) Cholangitis and the impact of endoscopic sphincterotomy. Gut 26:A553.

Patients with mild or severe pancreatitis who underwent emergency ERCP Decreased rates of biliary sepsis (0/97 vs 12/98

patients) Decreased rate of hospital morality (5 patients vs

9 patients)

Fan ST, et al .NEJM 1993(328)4.Cuschieri A, et al. Surg Endosc (1999)13:952-57.

“It is generally agreed that the two-stage approach (ERCP with endoscopic stone extraction followed by laparoscopic cholecystectomy) is indicated in poor-risk patients, including those with established cholangitis or severe pancreatitis.” Cuschieri 1999

Carr-Locke, DL. Therapeutic role of ERCP in the management of suspected common bile duct stones. Gastrointestinal Endoscopy2002(56)6.

Targarona EM, et al. Randomied trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high risk patients. The Lancet. 1996(347).

Endoscopic Sphincterotomy as Single Therapy

71 patients with both CBDS and gallbladder stones in whom endoscopic clearance of bile duct stones was achieved 3 pts underwent cholecystectomy within 1

week (acute cholecystitis) 42 pts - cholecystectomy was

recommended (based on specialist preference)

26 pts - wait and see strategy recommended5 pts underwent cholecystectomy with no worse

surgical outcomeKeulemans YCA, et al. Current management of the gallbladder after endoscopic sphincterotomy for common bile duct stones. Gastrointestinal Endoscopy 1997(46)6.

Endoscopic Sphincterotomy as Single Therapy

83 pts with CBDS enrolled in RCT of endoscopic sphincterotomy and stone removal vs surgery alone

5 year follow up7/39 ES pts underwent

cholecystectomy (6 for symptoms, 1 for cholecystitis)

2/39 ES pts died of gallbladder cancer Hammarstrom LE, et al. Long-term follow-up of a

prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br J Surg 1995;82(11)1516-21.

Endoscopic and surgical treatment of bile duct

calculi in middle-aged and elderly patients with gallbladder in situ are equally effective in the

long term -Hammarstrom

1995

Indications for Endoscopic Treatment of CBDS

Acute cholangitisGallstone pancreatitisElderly and high risk patients

Quality of Data Only two proscpective RCTs comparing

endoscopic to surgical treatment of common bile duct stones discovered intraoperatively

Numerous exclusion criteria: acute pancreatitis, acute cholangitis, anatomy precluding ERCP, ASA status 3-4, need for a drainage procedure of the CBD

Phillips EH, at al. Treatment of common bile duct stones discovered during cholecystectomy. J Gastrointest Surg (2008)12:624-28.

Surgeon Experience Over past 30 years: Number of cholecystectomies increased from

400,000 to 750,000 per year Rate of CBDE dropped from 20% to 2%

Only 15,000 CBDEs performed each year Published data comes from centers of

excellence No data on outcomes of procedures

performed by less experienced surgeons Number of CBDEs reported by finishing chief

surgery residents: 10 in 1990 (all open) 1.5 open and 0.8 laparoscopic in 2008

Phillips EH, at al. Treatment of common bile duct stones discovered during cholecystectomy. J Gastrointest Surg (2008)12:624-28.

Survey of 68 general surgeons practicing in rural USOnly 45% reported that they perform

LCBDE 75% reported that ERCP was preferred

approach to a patient with choledocholithiasis

Reasons for not performing LCBDE58% - time24% - equipment6% - lack of good GI backup3% - reimbursement1.5% - increased morbidity1.5% - lack of skill

Bingener J, Schwesinger WH. Management of common bile duct stones in a rural area of the US: Results of a survey. Surg Endosc (2006)20:577-79.

Application of LCBDE Data Taylor 2007 - Australia Campbell-Lloyd 2008 - Australia Poole 1997 - UK O’Neill 2008 - Australia Tang 2006 - Hong Kong Sgourakis 2002 - Greece Tinoco 2008 - Brazil Cuschieri 1999 - UK, Italy, Spain, Australia, Portugal,

The Netherlands Clayton 2006 - New Zealand, Greece Suc 1998 - France Neoptolemos 1987 - UK Tranter 2002 - UK Nathanson 2005 - Australia Rhodes 1998 - UK Gurusamy 2001 - UK

There are several approaches (to the management of CBDS) and

current data does not suggest clear superiority of any one approach; decisions regarding treatment are most appropriately made based on surgeon preference as well as the

availability of equipment and skilled personnel. (Level I, Grade A)

-SAGES Recommendations

Guidelines for the clnical application of laparoscopic biliary tract surgery: Practice/Clinical Guidelines published on 01/2010.

ConclusisonsEndoscpic management of CBDS: Optimal for elderly and high risk

patients Primary treatment for acute cholangitis

and gallstone pancreatitis Option as single therapy for common

bile duct stonesNo data to support use of LCBDE in US

Taylor CJ, Kong J, Ghusn M, White S, Crampton N, Layani L. Laparoscopic bile duct exploration: results of 160 consecutive cases with 2-year follow up. ANZ J Surg 2007;77:440-5

Campbell-Lloyd AJ, Martin DJ, Martin IJ. Long-term outcomes after laparoscopic bile duct exploration: a 5-year follow up of 150 consecutive patients. ANZ J Surg 2008;78:492-4.

Poole G, Waldron B, Shimi SM, Cuschieri A. Laparoscopic common bile duct exploration after failed endoscopic stone extraction. Endoscopy 1997 Sep:29(7):609-13.

O'Neill CJ, Gillies DM, Gani JS. Choledocholithiasis: overdiagnosed endoscopically and undertreated laparoscopically. ANZ J Surg 2008;78:487-91.

Tang CN, Tsui KK, Ha JP, Siu WT, Li MK. Laparoscopic exploration of the common bile duct: 10-year experience of 174 patients from a single centre. Hong Kong Med J 2006;12:191-6.

Sgourakis G, Karaliotas K. Laparsocopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir 2002 Aug;57(4)467-74.

Tinoco R, Tinoco A, El-Kadre L, Peres L, Sueth D. Laparoscopic common bile duct exploration. Ann Surg 2008;247:674-9.

Cuschieri A, et al. EAES multicenter proscpecitve randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc (1999)13:952-57.

Clayton ES, Connor S, Alexakis N, Leandros E. Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ. Br J Surg 2006;93:1185-91.

Suc B, et al. Surgery vs Endocsopy as primary treatment in symptomatic patients with suspected common bile duet stones: a multicenter randomized trial. Arch Surg, 1998;133:702-708.

Neoptolemos JP, Carr-Locke DL, Fossard DP. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones. British Medical Journal 1987Feb:294.

Tranter SE, Thompson MH> Comparison of endoscopic sphinctertomy and laparoscpic exploration of the common bile duct. British Journal of Surgery 2002(89)1495-1504.

Nathanson LK, et al. Postoperative ERCP versus laparoscopic choledochotomy for clearance of selected bile duct calculi: a randomized trial. Ann Surg 2005;242:188-192.

Rhodes M, et al. Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 1998;351:159-61.

Gursamy K, et al. Systematic review and meta-analysis of inraoperative versus preoperative endosocpic sphincterotomy in patients with galldbldder and suspected common bile duct stones. British Journal of Surgery 2001;98:908-916.