Management of Choledocholithiasis - Department of …€¦ · GAMAL MAREY SUNY DOWNSTATE MEDICAL...

GAMAL MAREY SUNY DOWNSTATE MEDICAL CENTER

3/19/2015

Management of Choledocholithiasis

www.downstatesurgery.org

Case Presentation 1/18

45 y/o male, presented with abdominal pain radiating to the back x 1 day, associated with nausea and vomiting

PMH- Depression, Neuropathy, GS pancreatitis, Stage IV

rectal CA with bladder invasion, s/p neoadjuvent chemo-XRT. PSH- APR, Radical cystectomy with ileal coduit 3/2011,

pelvic abscess drainage 4/2011

Allergy- NKDA Meds- Gabapentin, Naproxen, Oxycodone SH- no ETOH, no smoking or drugs


Physical Exam

VS: T 97.7 BP 127/87 HR 79 RR 20 O2

AAOx3, scleral icterus

Abdomen- obese, soft, + RUQ/epigastric tenderness, colostomy and urostomy.


Labs

CBC- 9.5/13.8/41.4/160

BMP- 139/3.5/104/27/18/0.9/192

LFTs – 7.5/4.0/159/166/140/5.1

Lipase- 32322 lactic acid- 2.2


Imaging

RUQ son- limited (body habitus)

CT abdomen- Cholelithiasis, Pancreatitis

MRCP- Gall bladder impacted with stones, extrahepatic ductal system dilated up to 9 mm, containing numerous gallstones.


Hospital Course

HD#1 NPO, Aggressive IV hydration, pain control, ERCP scheduled for 1/ 22.

LFTs- 6.9/3.6/125/170/144/4.2 lipase- 9510

HD#3 LFTs trending down, tolerated clears

LFTs- 6.3/3.0/45/97/115/3.9 lipase- 922

HD#4 s/p failed ERCP, unable to cannulate the ampulla, zosyn started for cholangitis ppx

LFTs- 6.1/2.8/27/76/110/1.7 Lipase- 263


Hospital Course

HD#5 Repeat MRCP showed the extra-hepatic ductal system is slightly less dilated, CBD measuring 6-9mm, with numerous intraductal calculi present similar to previously.

HD#6 LFTs WNL, started on clears, surgery scheduled for 1/26


Surgery

HD#8 s/p open cholecystectomy, CBD exploration, stones retrieval and T-Tube placement.

Right subcostal incision GB resected in retrograde

fashion


Surgery

1.5 cm longitudinal CBD incision

Many stone retrieved from CHD & CBD using

fogarty catheter

T- tube placed

JP drain

Pt. extubated in OR


Postoperative Course

POD#2 tolerated diet, LFTs WNL

POD#7 t-tube cholangiogram , no residual stones, t-tube clamped.

POD#9 discharged home 2/4


http://www.google.com/url?url=http://intranet.tdmu.edu.ua/data/kafedra/internal/onkologia/classes_stud/en/med/lik/ptn/Radiology/3/T8 Radiological examination of the liver, biliary tract and pancreas..htm&rct=j&frm=1&q=&esrc=s&sa=U&ei=dE0IVcX8NJGdyQSIx4GYCw&ved=0CBgQ9QEwAQ&sig2=1pvDdja5j3Nr7NQmKeZy8Q&usg=AFQjCNGYDWz45eODjT0bv9k-mJni-Tez2g

Goals

Introduction

Clinical Manifestations

Types of CBD stones

Diagnosis

Treatment options

Summary


Introduction

Over 20 million Americans have GB disease, 60%-80% are asymptomatic

650,000 to 700,000 cholecystectomies are performed every year

5 - 20 % of patients have choledocholithiasis at the time of cholecystectomy

AOC still carries a mortality rate of 10–20%


Introduction

98% of all biliary tract disorders are in some way related to gallstones.

In Western countries, bile duct stones in most cases of are secondary

Primary bile duct stones are much more common in patients of Asian descent


Clinical Manifestations (uncomplicated choledo.)

Nausea and vomiting

RUQ pain and tenderness

Jaundice

Courvoisier’s sign

Symptoms resolution-> passed the GS


Clinical Manifestations (complicated choledo.)

Gallstone Pancreatitis (elevated A/L)

Cholangitis (charcot’s triad)-> (Reynolds pentad)

Cirrhosis (long standing biliary obst.)


CBDS Types

Primary (de novo) stones o Brown stones (higher in bilirubin, lower in cholesterol) o Associated with biliary stasis and infection. o Common with aging, Asian descent, PSC, AIDS, primary hypothyrodism

o Secondary stones o Cholesterol stones (75%) from biliary stasis o Black stones (25%) Ca bilirubinate, from hemolytic disorders,

cirrhosis, prolonged fasting and TPN

Current Surgical Therapy 10th edition Cameron


Presenter

Presentation Notes

An underlying lithogenic bile composition (low-phospholipid associated cholelithiasis

Diagnosis

Laboratory tests

RUQ U/S-> 1st line, 25-68 % sensitivity for CBD stones

MRCP (sent./spec. 95%- 97%)

CT with contrast (sent./spec. 87%- 97%))

EUS (sent./spec. 95%- 98%)

ERCP (sent./spec. 95%-98%)- invasive

Intaoperative ultrasonography (sent./spec. 90%- 93%)

Intraoperative cholangiography (sent./spec. 98%- 94%)


Presenter

Presentation Notes

Elevated serum bilirubin and alkaline phosphatase typically reflect biliary obstruction, but these are neither highly sensitive nor specific for CBDS [22]. In a study by Anciaux et al., elevated serum gamma glutamyl transpeptidase (GGT) and alkaline phosphatase (ALP) were the most frequent abnormalities in laboratory valves of patients with symptomatic CBDS [10]. Serum bilirubin levels may be markedly elevated depending on whether the obstruction of the bile duct is complete or Incomplete ERCP complications include bleeding, duodenal perforation, cholangitis, pancreatitis, and bile duct injury

ASGE 2010 Guidelines

Very strong predictors

1. Positive CBD stone on U/S

2. Clinical acute cholangitis

3. Serum bilirubin >4 mg/dl

Strong predictors

1. Dilated CBD > 6mm

2. Serum bilirubin 1.8- 4 mg/dl


ACGE 2010 GUIDELINES

Moderate predictors

1. Abnormal liver biochemical test other than bilirubin

2. Age older than 55 years

3. Clinical gallstone pancreatitis


Risk stratification

High risk at least one very strong predictor and/or Both strong predictors, >50% -> ERCP and then elective cholecystectomy Intermediate risk One strong predictor and/or at least

one moderate predictor, 10-50% -> MRCP and EUS, If negative -> cholecystectomy, if MRCP negative but suspicion if high -> EUS or IOC, if positive -> ERCP

Low risk no predictors-> cholecystectomy


CBDS Treatment

Intervention or Surgery


Presenter

Presentation Notes

Today, therapeutic decision making is based on the local availability of expertise. Two groups of interventions have significant roles in management of CBD stones (1) pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST) in a two-stage procedure, (2) surgical bile duct clearance and cholecystectomy as onestage procedure. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient’ satisfaction, number and size of stones, and the surgeons experience

Treatment options

ERCP with or without endoscopic biliary sphincterotomy (EST)

Laparoscopic CBD exploration (transcystic or transcholedochal)

Laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure)

Biliary Drainage procedures


Presenter

Presentation Notes

Intervention or Surgery. Today, therapeutic decision making is based on the local availability of expertise. Two groups of interventions have significant roles inmanagement of CBD stones (1) pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST) in a two-stage procedure, (2) surgical bile duct clearance and cholecystectomy as one stage procedure. Several randomized controlled trials showed similar effectiveness for both methods of treatment A trans-cystic approach is generally used for small stones in a small bile duct whereas trans-ductal approach is preferred for large occluding stones in a large duct

Treatment options

Stone removal depends on when the stone is discovered. Before cholecystectomy-> ERCP During Cholecystectomy-> LCBDE- trans-

cystic duct, if it fails alternate approaches such as intraoperative or postoperative ERCP/EST, laparoscopic choledochotomy, or open CBDE


Presenter

Presentation Notes

treatment of CBDS [71]. ERCP/EST was performed with leaving the gallbladder in situ in patients with preoperative cholangitis or pancreatitis, older than 80 years of age, substantial comorbidity and where CBD stones were discovered. Although the success rate for stone clearance in isolated ERCP treatment is up to 87% to 97%, up to 25% of patients require two or more ERCP treatment [72]. This method is associated with morbidity and mortality rates of 5% to 11% and 0.7% to 1.2%, respectively [

ERCP/EST

Side viewing endoscope First ERCP 1968 First sphincterotomy 1973 Pre. or Post-operative ERCP is used for clearance of

retained CBDSs morbidity and mortality rates of 5% to 11% and 0.7% to

1.2%, respectively Recurrence rate 6-21% Biliary stenting as a bridge or as a definitive treatment


LCBDE-Trans-Cystic Approach.

Stone <6 mm, cystic duct >4mm, CBD <6mm, stone distal to cystic duct/CBD j., less than 6 stones with CBD.

Flush small stones after relaxing sphincter of oddi with 1-2 mg glucagon together with intraop. cholangigram

Fluoroscopic balloon cath. and wire basket sweep If stones 4-8mm, use choledochoscope If stone>1cm, choledochotomy LCBDE is as effective as ERCP 88-100% success rate i

ACS surgery: principles & practice 2009


Presenter

Presentation Notes

Laparoscopic common bile duct exploration (LCBDE) was associated with successful stone clearance rates ranging from 85% to 95%, a morbidity rate of 4%–16% and a mortality rate of around 0%–2% If LCBD-trans fails, alternate approaches such as intraoperative or postoperative ERCP/EST, laparoscopic choledochotomy, or open CBDE may be used [94]. A trans-cystic approach is generally used for small stones in a small bile duct whereas trans-ductal approach is preferred for large occluding stones in a large duct, intrahepatic stones, or aminiscule or tortuous cystic duct LCBDE-Trans-Cystic Approach. In the trans-cystic approach,100–200mL isotonic sodium chloride solution with 1–2mg glucagon (for relaxation of Oddi’s sphincter) is used to irrigate the CBD in an attempt to flush small stones through the sphincter of Oddi or out through the opening in the cystic duct. If this is not successful, a helical basket can be passed over a guide wire through the cystic duct to extract stones under fluoroscopic guidance [96]. Today, LCBDE under fluoroscopic guidance seems to be the procedure of choice. If this procedure fails, a choledochoscope (≤10 Fr) should be subsequently attempted in order to remove the stones under direct sight

LCBDE-Trans-Ductal Approach.

Failed trancystic approach, stones >6mm, cystic duct <4mm, multiple stones, stones to cystic duct/CBD J..

After the stones are removed under endoscopic visualization, the ductotomy is usually closed either primarily or over an appropriately sized T-tube

T-tube insertion is decompression of the duct in patients with residual distal obstruction, ductal imaging in the postoperative period and providing an access route for the removal of residual CBD stones


T-Tube Management

Fluid & electrolytes disturbance, Bacteremia, dislodgment of the tube, obstruction, or fracture of the tube, biliary stricture, biliary peritonitis, biliary fisulas. T-T Morbidity 10-20%

Repeat cholangiogram through T-tube If no stones , removal of T-tubes has been suggested as early

as 5–6 days postoperatively and as late as 4–5 weeks after surgery

Retained stones -> stone retrieval percutaneously after 4-6

weeks.


Open CBD exploration

Failed ERCP, failed laparoscopic attempts, surgeon’s comfort

1-2 cm incision in CBD anterior wall with 2 stay sutures

Arterial supply at 3 & 9 o’clock

Use forceps, fogarty, wire baskets and dilators


PTC

Previous gastric surgery

Cholangiohepatitis with distal obstructing CBDS that failed ERCP

Extensive intrahepatic stone disease.


Choledochal Drainage Procedures

Transduodenal sphincterotomy

Choledochoduodenostomy

Choldochojejunostomy


Choledochal Drainage Procedures Indications

Dilated CBD ≥1.5 cm with multiple stones Irremovable, impacted, distal CBD stones

Recurrence after previous duct exploration

Recurrence after EST

Distal CBD obstruction from tumor or stricture


Transduodenal Sphincterotomy

Stone impacted in ampulla of vater, papillay stenosis, multiple stenosis particularly in non-dilated duct, CBD exploration failure

Kocherize duodenum

Cannulate ampulla by passing fogarty into CBD

Longitudinal duodenoomy over ampulla

Schwartz’s principles of surgery, 10th Edition


Transduodenal Sphincterotomy

Sphincterotomy at 11 o’clock with sequential sutures

Biliary dilator the size of CBD

Close duodenotomy in transverse direction

Place a drain




Recurrent stones, impacted giant stones, ampullary stenosis.

Kocherize duodenum 1-2 cm distal choledochotomy Clear CBD stones Longitudinal duodentomy A diamond-shaped anastomosis is performed with

interrupted absorbable sutures, side to side single layerd anastomosis

Place a drain Schwartz’s principles of surgery, 10th Edition



Complications

Cholangitis 0-6%

Sump syndrome

Wound infection

Anastmotic leak

Intrabdominal abscess

70-80% asymptomatic after 5 years


Roux-en-y loop Choledochojejunostomy

Retrocolic 45- 60 cm roux-en-y end to side anastomosis

Interrupted absorbable sutures

Protect against intestinal reflux & secondary cholangitis

Place a drain



Other Treatment Modalities

Electrohydraulic Lithotripsy (EHL), rarely used

Extracorporeal Shockwave Lithotripsy (ESWL), before an ERCP (90% success rate)

Laser Lithotripsy (64-97% success rate)

Current Surgical Therapy 10th Eidition Cameron


Primary closure after laparoscopic common bile duct exploration versus T-tube Zhi-Tao Dong, MD, Guo-Zhong Wu, MD, , Kun-lun Luo, MD, Jie-Ming Li, MD

Single center randomized prospective study from 2001-2012

194 patient Group A, 101 ( LCBDE with primary closure) Group B, 93 ( LCBDE with T-tube drainage)

Inclusion Criteria : CBDS>6mm, CD<4mm, numerous stones, dilated CBD>6, stones in CHD.

All pts had intraop. Cholagiography and choledochoscopy Results: intraoperative findings, complications, LOS, Hospital

expenses Pubmd 2014 Mar ch


Complications Group A (N = 97) Group B (N = 90)

Postoperative bleeding 1 2

Pancreatitis 1 0

Bile leakage 5 4

Retained stone in CBD 4 3

Stricture of bile duct 0 0

Complications related to T-tube

Bile peritonitis after T-tube removal 0 2

Dislocation of drain 0 1

Pneumonia 1 2

Wound infection 1 1

Total 13 15


Outcome measures Group A (N = 101) Group B (N = 93) P

Diameter of CBD (mm) 11.75 ± 3.5 11.34 ± 4.1 0.743

Conversion to open surgery (%) 4 (3.96) 3 (3.23) 0.784

Operating time (min) 102.6 ± 15.2 128.6 ± 20.4 0.017

Intraoperative blood loss (mL) 35.2 ± 14.5 45.2 ± 17.4 0.164

Interval between surgery and getting out of bed (hr) 13.5 ± 4.8 15.3 ± 5.3 0.856

Interval between surgery and recovery of GI function (hr) 21.3 ± 5.6 25.9 ± 9.8 0.458

Postoperative hospital stay (d) 3.2 ± 2.1 4.9 ± 3.2 0.023

Hospital expenses (REN MIN BI) 11,278.9 ± 479.1 12,436.7 ± 879.3 0.041

Complications (%) 13 (12.87) 15 (16.13) 0.518


Summary

Most patients with choledocholithiasis are symptomatic, although occasional patients are asymptomatic U/S, MRCP are diagnostic modalities for CBDS ERCP followed by cholecystectomy for patients with

high risk of CBD stones LCBDE (trans-cystic or trans-ductal) is a standard

method with a high efficacy and low morbidity and mortality for the treatment of CBDS


Summary

ERCP should be performed as a first step and in the event of failure LCBDE can be performed

Open approach (Biliary drainage procedures ) always remains as a final option when others modalities have failed


References

1. Current Surgical Therapy 10th Eidition Cameron

2. Schwartz’s principles of surgery, 10th Edition

3. ASGE Standards of Practice Committee, Maple JT, Ben-Menachem T, et al. The role of endoscopy in the evaluation of suspected choledocholithiasis. Gastrointest Endosc 2010; 71:1

4. Prat F, Meduri B, Ducot B, et al. Prediction of common bile duct stones by noninvasive tests. Ann Surg 1999; 229:362

5. Carboni M, Negro P, D'Amore L, Proposito D. Transduodenal sphincteroplasty in a laparoscopic era. World J Surg. 2001;25:1357–1359

6. Ellison CE, Melvin WS, Moon SG. Current Application of Lateral Choledochoduodenostomy and Transduodenal Sphincteroplasty. In: Baker RJ, Fischer JE, eds. Mastery of Surgery, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006

7. Ellison CE, Carey LC. Cholecystostomy, Cholecystectomy, and Intraoperative Evaluation of the Biliary Tree. In: Baker RJ, Fischer JE, eds. Mastery of Surgery, 5th ed. Philadelphia, PA: Lippincott Williams & Wilkins; 2006

8. Hutter MM, Rattner DW. Open Common Bile Duct Exploration: When Is It Indicated? In: Cameron JL, ed. Current Surgical Therapy, 8th ed. St Louis, MO: Mosby; 2004


Thank You


Management of Choledocholithiasis - Department of …€¦ · GAMAL MAREY SUNY DOWNSTATE MEDICAL...

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Transcript of Management of Choledocholithiasis - Department of …€¦ · GAMAL MAREY SUNY DOWNSTATE MEDICAL...