Guidelines Management of Common Bile Duct Stones

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  • *DR.MUHAMMAD ABUKHATER*Guidelines Management of Common Bile Duct Stones Presented by: DR.MUHAMMAD ABUKHATERFRCS IRELAND

    21/September /2011

    DR.MUHAMMAD ABUKHATER

  • *DR.MUHAMMAD ABUKHATER*

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  • Biliary tract stones can be found in any location*DR.MUHAMMAD ABUKHATER*

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  • *DR.MUHAMMAD ABUKHATER*When patients present with CBD StoneWhat is the best modality of treatment ?

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  • CBDSCommon bile duct stones (CBDSs) may occur in up to 3%14.7% of all patients for whom cholecystectomy is preformed

    CBDS have symptoms It is important to distinguish between primary and secondary stones

    *DR.MUHAMMAD ABUKHATER*

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  • ERCP with or without endoscopic biliary sphincterotomy

    Laparoscopic CBD exploration (Transcystic or Transcholedochal)

    Laparotomy with CBD exploration (by T-tube insertion, or primary closure) *DR.MUHAMMAD ABUKHATER*

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  • *DR.MUHAMMAD ABUKHATER*.Technical successSafetyCost effectivenessIt is the first line investigation in patients with suspected CBDS Specificity 95%Sensitivity 25% to 63%

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  • *DR.MUHAMMAD ABUKHATER*ERCPSensitivity 90% to 95%Specificity 92% to 98%Morbidity rate of 15.9% and a mortality rate of 1%

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  • *DR.MUHAMMAD ABUKHATER*The Reasons to Perform a Sphincterotomy

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  • *DR.MUHAMMAD ABUKHATER*Residual or recurrent common bile duct stones following cholecystectomyBiliary pancreatitis Papillary stenosis due to a tumor or scarring To facilitate the placement of a stent. Common bile duct stones in high-risk surgical patients with intact gallbladders

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  • MRCPAccurate, noninvasive diagnostic modality for investigating the biliary ducts

    Sensitivity of 95% and a specificity of 97%*DR.MUHAMMAD ABUKHATER*

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  • *DR.MUHAMMAD ABUKHATER*What are Diseases Diagnosed by MRCP ?

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  • *DR.MUHAMMAD ABUKHATER*(MRCP)

    Biliary Disease Cystic disease of bile duct (choledochal cyst, choledochocele, Carolis disease) Congenital variants (low or medial duct insertion, aberrant right hepatic duct) Choledocholilithiasis Primary sclerosing cholangitis Post-surgical biliary complications Cholangiocarcinoma, Klatskin Tumor of the Bile Duct Pancreatic Disease Pancreas divisum Chronic pancreatitis Pancreatic cancer

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  • EUSEndoscopic insertion of an ultrasound probe through the stomach and up to the second half of the duodenumNoninvasive testHighly dependent on the examiner

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  • *DR.MUHAMMAD ABUKHATER*Sensitivity 95%, Specificity 9598%

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  • *DR.MUHAMMAD ABUKHATER*EUS has a high sensitivity and specificity for detection of common bile duct stones, equal to or better than that of (ERCP), without the risks of ERCP-related pancreatitis

    Laurent Palazzo from the University of Paris

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  • Conventional Computed Tomography (CT)Sensitivity of 87% and a specificity of 97% for the diagnosis of CBD stones

    Risk of allergic reaction to contrast injection *DR.MUHAMMAD ABUKHATER*

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  • Intraoperative Cholangiography (IOC)Routine use of IOC is still controversialIdentify choledochal stones Open or laparoscopic cholecystectomySensitivity of 98% and Specificity of 94%Retained stonesCBD injuries Operative time *DR.MUHAMMAD ABUKHATER*

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  • Intervention or SurgeryToday, therapeutic decision-making is based on the local availability of expertisepre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST) in atwo-stage proceduresurgical bile duct clearance and cholecystectomy as one-stage procedure*DR.MUHAMMAD ABUKHATER*

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  • Kharbutli et al. reported that one-stage management of symptomatic CBDS is associated with less morbidity and mortality (7% and 0.19%) Than two-stage management (13.5% and 0.5%)*DR.MUHAMMAD ABUKHATER*

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  • Intervention or Surgery(ERCP)Endoscopic biliary sphincterotomy (EST)Endoscopic balloon dilation of the papillaShort-term use of a biliary stent *DR.MUHAMMAD ABUKHATER*

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  • Intervention or SurgeryLaparoscopic Common Bile Duct Explorationsurgical expertiseadequate equipmentbiliary anatomynumber and size of CBD stones stone clearance rates ranging from 85% to 95%, a morbidity rate of 4%16% and a mortality rate of around 0%2%

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  • Postoperative Evaluation and ManagementRetained stones are discovered after an operation (2.5%)

    laparoscopic or open exploration

    Percutaneous transhepatic therapies *DR.MUHAMMAD ABUKHATER*

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  • 1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon

    Kocherization of duodenum and short longitudinal choledochotomyStones removed with palpation, irrigation with flexible catheters, forceps, Completion with T-tube drainageFor many years, this was the standard treatment for cholecystocholedocholithiasis

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  • Open Common Bile Duct ExplorationCholedochoenterostomy / CBD> 2 CM A- Side-to-side choledochoduodenostomy B- Choledochojejunostomy with a roux-en-Y loop

    Sphincterotomy

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  • CBD Exploration1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon

    Kocherization of duodenum and short longitudinal choledochotomyStones removed with palpation, irrigation with flexible catheters, forceps, Completion with T-tube drainageFor many years, this was the standard treatment for cholecystocholedocholithiasis

    *DR.MUHAMMAD ABUKHATER*

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  • CBD Exploration*DR.MUHAMMAD ABUKHATER*Ideal for patient with 1- 3 distal stonesNon dilated ductswith or without T- tube insertion

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  • Choledochoduodenostomy*DR.MUHAMMAD ABUKHATER*

    Introduced by Sprengel 1891

    CBD must be > 2 cm

    Low morbidity and mortality

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  • Choledochojejunostomy*DR.MUHAMMAD ABUKHATER* Can be performed for CBD < 2 cm

    Following previous open CBD exploration

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  • Transduodenal Sphincterotomyand Sphincteroplasty*DR.MUHAMMAD ABUKHATER* Used primarily for impacted stones at the ampulla

    Definitive treatment of ampullary stenosis

    Access to pancreatic duct

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  • Open Common Bile Duct ExplorationIt should not be forgot that the open approach always remains as a final option when others modalities have failed*DR.MUHAMMAD ABUKHATER*Various Techniques for the Surgical Treatment of Common Bile Duct Stones: A Meta Review1Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran 2Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany

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  • *DR.MUHAMMAD ABUKHATER*1-Which of the following is single best predicting factor for presence of CBD Stones ? A- Alkaline phosphataseB- AST C- Total bilirubin D- Amylase

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  • *DR.MUHAMMAD ABUKHATER*2- CBD stones found in a patient one year after cholecystectomy are most likely A- RetainedB- RecurrentC- PrimaryD- b and c

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  • *DR.MUHAMMAD ABUKHATER*3- When sphincterotomy or papillotomy are unsuccessful, the surgeon can perform which of the following for proper drainage of CBD stones A. Choledochotomy and stone retrievalb. Transduodenal sphincteroplastyc. Choledochoduodenostomyd. Choledochojejunostomye. All of the above

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  • *DR.MUHAMMAD ABUKHATER*4- When the ampulla is exposed through duodenal access, what is the preferred incision for access to the CBD A. 5 o clockb. 3 oclockc. 11 oclockd. 2 oclocke. 12 oclock

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  • *DR.MUHAMMAD ABUKHATER*March 25, 2008 New guidelines issued for management of common bile duct stones (CBDS) have been published in the March 5 Online First issue of Gut.

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  • *DR.MUHAMMAD ABUKHATER*The British Society of Gastroenterology (BSG) commissioned these guidelines, which were subsequently reviewed, revised, and endorsed by the Clinical Standards and Services Committee of the BSG, the BSG Endoscopy Committee, the ERCP stakeholder group, the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, and the Royal College of Radiologists

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  • *DR.MUHAMMAD ABUKHATER*After a preliminary search of the literature in 2004 of PubMed and MEDLINE, the findings were summarized and were presented to the British Society of G