“More Than You Bargained For ” Dr Asif Khan. Case 1 38 y/o female. Rt upper quadrant pain and...
-
Upload
jody-stephens -
Category
Documents
-
view
219 -
download
4
Transcript of “More Than You Bargained For ” Dr Asif Khan. Case 1 38 y/o female. Rt upper quadrant pain and...
Case 1
38 y/o female. Rt upper quadrant pain and vomiting, deranged LFT’s
(obstructive picture) PMH includes ERCP
Two stones 8 and 10mm identified but unable to remove, stent was placed and sphincterotomy performed.
Laparoscopic Cholecystectomy
MRCP 2007
Clinical Exam
Afebrile, hemodynamically stable. Scleral icterus. Abdomen soft, mildly tender , negative Murphy’s sign. No rebound tenderness/guarding, no masses appreciated. Blood Results:
WBC 4.6 x 109/L (4-10 109/L ) AST 258 IU/L (14-54 ) ; ALT 352 IU/L (14-54) Billirubin 77 umol/L (3.4-20.5) Alkaline phosphatase 258 IU/L ( 42-121) INR 1.1
Investigations U/S – Dilated CBD (14mm) containing two stones, one
13 mm.
ERCP attempted Blocked stent , dilated CBD , two large stones >1cm in size, small stones and sludge. Stent changed and surgical intervention suggested as stones unretrievable via ERCP
MRCP – planning – pre IRConfirms ductal stones and dilated ducts
Prominent ducts especially those beyond the stones in the right radicular duct system. Modified Burhenne PTC technique - feasible
Management
PTC and cannulation guide wire technique
Modified “ Burhenne” technique
Over the wire Fogarty Balloon - push
Stones were pushed into the duodenum and stent inserted. CBD was cleared.
Post Procedure Post interventional radiology,
Patient made good recovery
Discharged home no further episodes.
LFT’s normal.
Case 2
72 y/o female. Admitted with RUQ pain , fever and jaundice. Clinical picture of Cholangitis treated with IV antibiotics ,fluid
resuscitation and analgesia. Recurrent admission for symptomatic choledocholithiasis and
repeated ERCP attempts ERCP 1 -failed ERCP 2 -failed ERCP 3 -failed
Investigations
US Abdomen –Multiple gall stones and CBD diameter 1.1 cm.
MRCP - Gall stones and multiple ductal stones , dilated CBD.
ERCP - Unable to remove stones and stent was inserted.
Management
Open cholecystectomy and CBD Exploration performed.
Findings: More than 12 big and small stones removed from CBD. Normal anatomy.
Duct clear on choledochoscopy.
T tube cholangiogram Day 7 post op Findings: Two retained stones in Rt duct system.
Management
Percutaneous approach to stone clearance Modified “Burhenne technique” – push. T –tube track. Duct cannulation per T tube track. Catheter –wire contrast
technique Over the wire Fogarty Balloon stone pull - push to duodenum.
Management Overnight external drain Check cholangiogram following morning.
Findings: Duct clear. External drain removal LFT’S normal.
Discussion Last 30 years have seen major advances in the
management of gallstone disease, which in the U.S. alone, costs over 6 billion dollars per annum to treat.
In patients who have cholecystectomy for gallbladder stones, approximately 10% to 18% also have common bile duct (CBD) stones.
Pathogenesis
CBD Stones Primary CBD stones
Bilirubin is dominant component. Secondary CBD Stones
Descend from the gallbladder Cholesterol is dominant component.
Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 page
Clinical Presentation Asymptomatic Symptomatic
Biliary colic with pale stools, dark-colored urine and pruritis.
Cholangitis or gallstone pancreatitis.
Acute obstructive cholangitis is a life-threatening complication caused by an infection secondary to biliary obstruction.
Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages doi:10.1155/2009/840208
Diagnosis
Investigation Sensitivity Specificity
US 25-82% 56-100%
EUS 95 % 95-98 %
MRCP 95 % 97 %
CT 87 % 97 %
Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages
Management Options– CBD StonesManagement Options– CBD Stones
Open cholecystectomy + CBD exploration.Open cholecystectomy + CBD exploration.
ERCP + Endoscopic Sphincterotomy (followed by ERCP + Endoscopic Sphincterotomy (followed by cholecystectomy – most frequently used).cholecystectomy – most frequently used).
Laparoscopic cholecystectomy + Laparoscopic CBD Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in specialized centers.exploration – in specialized centers.
Choledochoscopy at laparoscopy or percutaneous Choledochoscopy at laparoscopy or percutaneous choleydochoscopy or choleydochoscopy through choleydochoscopy or choleydochoscopy through T tube. T tube.
CBD stonesCBD stones ERCP has become a popular technique to clear CBD stones.
Currently in the laparoscopic era studies have shown that laparoscopic treatment of CBD stones is possible and is potentially as effective as ERCP.
This is most commonly done by a transcystic approach, though evidence of success in large volume cohorts with a more technically demanding laparoscopic Choledochotomy is emerging .
(Fletcher 1994 ;Cuschieri 1996; Lezoche 1996)
ERCPERCP
Despite the fact that therapeutic ERCP is increasingly being used to manage biliary tract diseases, the procedure remains compounded by two persistent problems: failure of successful biliary cannulation, and post ERCP-pancreatitis (PEP).
PTC and guide-wire cannulation has been proposed as a simple way to avoid PEP.
Lella F, Bagnolo F, Colombo E, Bonassi U. A simple way of avoiding post- ERCP pancreatitis. Gastrointest Endosc 2004; 59: 830-834.
Bailey AA, Bourke MJ, Williams SJ, et al. A prospective randomized trial of cannulation technique in ERCP: Effects on technical success and post-ERCP pancreatitis. Endoscopy 2008; 40: 296-301.
Management – CBD StonesManagement – CBD Stones
Burhenne technique Burhenne technique Treatment of retained CBD stones found on T tube cholangiography Treatment of retained CBD stones found on T tube cholangiography Technique modified by ERCP and sphincterotomy practice Technique modified by ERCP and sphincterotomy practice
Percutaneous extraction or duodenal deposition under fluoroscopic control. Catheter –wire – contrast - balloonPercutaneous extraction or duodenal deposition under fluoroscopic control. Catheter –wire – contrast - balloon Approach depends on ? +/- sphincterotomy Approach depends on ? +/- sphincterotomy Percutaneous sphincteroplasty - alternativePercutaneous sphincteroplasty - alternative
British Journal of SurgeryVolume 78 Issue 8, Pages 959 - 960British Journal of SurgeryVolume 78 Issue 8, Pages 959 - 960
Vanderburgh L, Yeung EY, Ho CS. Radiologic management of problematic biliary calculi. Vanderburgh L, Yeung EY, Ho CS. Radiologic management of problematic biliary calculi. Sem Intervent RadiolSem Intervent Radiol1986; 13:69 –771986; 13:69 –77
Management – CBD StonesManagement – CBD Stones
Percutaneous therapy is the option before resorting to surgery. Fluoroscopically-guided extraction of resident calculi through a
sinus tract T tube (Kher tube) is a well-established procedure. If no T tube is in place, a transhepatic approach may be attempted. “Rendez-vous”technique. Combined percutaneous IR and
endoscopic ERCPprocedure
Burhenne HJ. Percutaneous extraction of retained biliary tract stones: 661 patients. AJR1980
Rendez-vous guide-wire technique
The PTC guide-wire technique seems to reduce the incidence of post-ERCP pancreatitis in the elderly as compared to the conventional contrast technique, but does not appear to improve the primary success rate for biliary cannulation during ERCP in this population.
Lazaraki G, Katsinelos P. Prevention of post- ERCP pancreatitis: an overview. Ann Gastroenterol 2008; 21: 27-38.
Adjuvant Techniques with ERCPAdjuvant Techniques with ERCP+ES+ES
Laparoscopic CBD exploration/Choleydochoscopy.Laparoscopic CBD exploration/Choleydochoscopy. Mechanical lithotripsyMechanical lithotripsy LASER lithotripsyLASER lithotripsy Electrohydraulic lithotripsyElectrohydraulic lithotripsy ESWLESWL Chemical contact dissolution therapyChemical contact dissolution therapy