Management of bile duct stones

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  • Management of CBD stonesin the Era of LaparoscopyDr.S.Easwaramoorthy MS FRCS (Eng), FRCS (Edin), FRCS (Glasgow)Consultant Surgeon, Lotus Hospital, ErodeEC member, IAGES South ZoneChairman Elect, ASI TN & P ChapterExaminer for MRCS (RCS of Edinburgh)FIAGES@ Jaipur 2016

  • 10% of Patients with Gall stones have associated CBD stones.

  • CBD stones can have deadly consequencesCholangitis & Septicemia

    Gall Stone Pancreatitis

  • CBD Stone: PresentationCholangitisCharcots triadIntermittent painIntermittent feverIntermittent jaundiceReynolds PentadHypotentionConfusionObstructive JaundicePancreatitisAsymptomatic

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  • Biochemical DiagnosisPredicting factorsLiver function tests Bilirubin >3gm Alkaline phosphataseTransaminases: SGOT/SGPTGamma GTKook P et alDo Pre operative indicators predict the presence of CBD stones during lap chole?Am J Surg, 495-499, 1996Normal Liver profile does not exclude CBD stones

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  • Radiological DiagnosisUS abdomenCT abdomenMRCPEUSERCP

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  • 1. US abdomenNon InvasiveDiagnosticDilated CBD: >6mmLow sensitivityNormal Ultrasound can not exclude CBD stone

  • InvasiveDiagnosticSensitive testButOperator DependentAvailability?2. Endoscopic US

  • 3. CT abdomenStomachAortaSpleenNon InvasiveDiagnosticMassLiverCBD stone

  • Non InvasiveDiagnosticTest of Choice4. MRCPBile duct with stonePancreatic duct

  • 5. ERCP For Bile Duct StonesTreatmentOfChoiceInvasiveEssentially Therapeutic

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  • Pre operative risk assessmentHigh risk (>50%): ERCPClinical Jaundice, CholangitisBilirubin > 3mgmCBD > 6mm, Stone in CBDModerate risk ( 10-50%): MRCP/EUS/ICH/O of Jaundice or pancreatitisMultiple small stones in GBRaised Al.Phosphatase and bilirubinLow risk ( < 5%):Normal Liver profileUS: Normal CBD. Large stone in GBNo H/O of Jaundice or pancreatitis

    ASGE Standards of Practice Committee et al 2010

  • What will you do prior to Lap chole?5

  • Pre operative risk assessmentHigh risk (>50%): ERCPClinical Jaundice, CholangitisBilirubin > 3mgmCBD > 6mm, Stone in CBDModerate risk ( 10-50%): MRCP/EUS/ICH/O of Jaundice or pancreatitisMultiple small stones in GBRaised Al.Phosphatase and bilirubinLow risk ( < 5%):Normal Liver profileUS: Normal CBD. Large stone in GBNo H/O of Jaundice or pancreatitis

    ASGE Standards of Practice Committee et al 2010

  • What will you do next?6

  • Pre operative risk assessmentHigh risk (>50%): ERCPClinical Jaundice, CholangitisBilirubin > 3mgmCBD > 6mm, Stone in CBDModerate risk ( 10-50%): MRCP/EUS/ICH/O of Jaundice or pancreatitisMultiple small stones in GBRaised Al.Phosphatase and bilirubinLow risk ( < 5%):Normal Liver profileUS: Normal CBD. Large stone in GBNo H/O of Jaundice or pancreatitis

    ASGE Standards of Practice Committee et al 2010

  • ERCP TeamEndoscopy Team

    Radiology Team

    Anaesthetic Team

    Nursing Team

  • ERCP

  • ERCP: Diagnostic aspectsImpacted stonePouring out PusRoad Map

  • Side Viewing Scope & AccessoriesBalloon, Basket & Biopsy forceps

  • ERCP : Therapeutic AdvantageSphincterotomyBalloon SweepLithotripsySelective CannulationSphincteroplasty

  • ERCP: Multiple CBD stonesSphincterotomyBalloon SweepDormia

  • About ERCPA word of Caution!Only used as therapeutic modalityDuct Cannulation rate: 95%Duct Clearance rate : 90%ComplicationsPancreatitis: 5%Bleeding : 3%Perforation: 1%Mortality: 1%

  • 7What is the standard of Care for this lady

  • Pre operative DiagnosisStandard of Care

    Pre op ERCPLap choleOpen Chole and CBD exploration

    Lap cholePost op ERCPLap chole and Lap CBD exploration

    ConsiderLocal resources and expertiseMorbidity and cost effectiveness

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  • Laparoscopic management of CBD stones1. Transcystic approachWhenSize of the stones : smallSize of cystic duct : >4mmCystic duct entranceHowCholangiogramDilatationCholedochoscopyExtraction of stones

  • 2. Lap CBD Exploration

    Exposure of CBDVertical CholedochotomySqueeze techniqueFlushing TechniquesBalloon sweep techniqueBasket techniqueCholedochoscopic technique

    WhenDilated ductLarge stonesAlso proximal stones

  • Lap CBD ExplorationCase SelectionExpertiseEquipmentsLap suturing C arm and cholangiogramStone retrival gadgetsDormia/Balloon/ Choangioscope Vs NephroscopeT tube/StentAdditional monitors

  • Lap CBD Exploration: Options

    EHL/Laser LithotripsyStent/T tube/Primary sutureCholedocho duodenostomy

  • Choledocho-duodenostomyIndication:CBD > 2cm/multiple stones and sludge with stricture lower end/elderly pt

    Operation:Open Vs LapVertical supra-duodenal choledochotomyLongitudinal duodenotomy : 1st partInterrupted 3-0 vicryl

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  • Intra operative diagnosis of Bile duct stones(During Lap Chole)Operative CholangiogramRoutineSelectiveSuspected CBD stoneUnclear anatomy

    Intra operative Ultrasound

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  • Management of CBD stonesAcc to Time of DiagnosisPre-operative Intra- operativePost -operative

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  • Standard of CareLap chole/Post op ERCPLap chole/Lap CBD explorationConvert to Open chole and CBD exploration

  • POST - OPERATIVE DIAGNOSIS(Minus GB)ERCPMRCPT tube Cholangiogram

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  • 60/M with 4 months history of fever and abdominal pain on and off. H/o cholecystectomy 10 years ago.He also gave history Of passing dark urine at least in 2 occasion. Following US , the patient underwent MRCP

  • MRCP10

  • MRCPNon InvasiveDiagnosticCBDStoneTest Of Choice

  • ERCP : Your diagnosis?

  • A case of Gall Stone PancreatitisNeedle Knife SphincterotomyImpacted stone at Ampula34/M presented with severe abdominal and back pain for 3 days. Serum amylaseWas 2016 units. US abdomen showed multiple small gall stones and dilated CBDAnd enlarged pancreas. In view of unabated pain, fever, and jaundice, the patientUnderwent ERCP.

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  • Severe Biliary PancreatitisRole of Early ERCPNeoptolemos et alLancet 2: 976-983, 1988Fan et alN Engl J Med 328: 228-232, 1993Less morbidityShorter hospital stayTrend towards lower mortality?

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  • Recent AdvancesLithotripsyMechanicalElectro hydraulicLaserCholedochoscopySpy GlassRendezvous techniqueBioluminence Cholangiogram

  • Advances in ERCPMother & Baby Cholangioscopy

  • Spyglass choledochoscopyAdvances in ERCP

  • Novel way of treating difficult bile duct stones

  • ConclusionMinimal Access-Maximum SuccessMRCP is the Test of Choice ERCP is the Treatment of ChoiceLap CBD exploration requires adequate training and appropriate equipmentsBile ducts stones need special attention

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