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    Dr. Abhishek Saraf

    Moderator: Dr. Vinod JainMS, FAIS, FIMSA, FLCS, FMAS, MAMS

    RECENT MANAGEMENT

    OF CALCULOUS BILIARY

    DISEASE

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    Types of biliary calculiSite of origin Primary

    Secondary

    Retained/ recurrent

    Location

    Gall bladder

    Intra hepatic

    Extrahepatic

    Both intrahepatic and extrahepatic

    Composition

    Cholesterol stones (85%) (pure/mixed)

    Pigment stones(15%)

    Black stones

    Brown stones

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    Pathogenesis of cholesterol stones* 3 elements

    *harrison 16/e, p1880, maingots 10/e, p1718

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    Predisposing factors for cholesterol stones Demographic/ genetic factors

    Obesity

    Weight loss

    Female sex hormones: natural estrogens, OCPs.

    Increasing age

    Gall bladder hypomotility

    Clofibrate therapy

    Decreased bile acid secretion

    Decreased phoshpholipid secretion Miscellaneous : high cholesterol diet, spinal cord injury

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    Predisposing factors for pigment gallstoneformation

    Demographic / genetic factors: Asia, rural setting

    Chronic hemolysis

    Alcoholic cirrhosis

    Pernicious anemiaChronic biliary tract infection, parasite infection [E.

    coli, ascaris lumbricoids, clonorchis sinensis]

    Increasing age

    Ileal disease, ileal resection or bypass

    Cystic fibrosis

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    Prevalence and incidence Prevalence [autopsy reports]: 11 to 36% Affected by age, gender, ethnic background and otherpredisposing

    conditions as discusser earlier

    times more common in women

    2 fold greaterprevalence in first degree relatives of patients withgall stones.

    Acute cholecystitis is secondary to gall stones in 90-95% cases.

    CBD stones are found in 6-12%of patients with gall bladder stones.

    Indian data on gall stones: 35% women & 20% men would developG.B. stones by 75 year More common in North India

    Cholesterol stones common in North India (Dietetic Etiology)

    Pigment stones more common in South India (infective Etiology)

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    Manifestations, sequel & complications ofbiliary calculi

    In Gall Bladder In Bile Ducts In Intestine

    Silent stones

    Acute cholecystitisChronic cholecystitisMucoceleEmpyemaPerforationGangreneCarcinoma (0.5-3%)

    Obstructive jaundice

    CholangitisAcute pancreatitisMirizzis syndrome

    Acute intestinal

    obstruction (gallstone ileus)

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    Investigations

    Hematological:

    LFT:usually normal in acute/ chronic cholecystitis. Increased bilirubin (direct),alkaline phosphates, GGT and transaminases in choledocholithiasis/ cholangitis

    TLC, DLC: mild- moderate leukocytosis (12000-15000) in acute choecystitis.High TLC (>20000) in GB empyema, perforation, cholangitis, pancreatitis.

    S. amylase and lipase:increased in pancreatitis

    Radiological:

    Plane radiographs: only 10 % gall stones are radio opaque

    Air in biliary tract with features of intestinal obstruction: gall stone ileus

    Mercedes benz / seagull sign.

    Gas in biliary tract: in biliary-enteric anastomosis, ERC sphincterotomy

    USG-IOC for gall bladder stones, acute and chronic cholecystitis

    Gall bladder stones: hyperdense, posterior acaustic shadow, moves with change ofposition. WES (wall echo shadow) sign

    Acute cholecystitis: thickened GB wall, pericholecystic fluid, probe murphys sign

    Chronic cholecystitis: contracted, thick walled gall bladder

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    Investigations Dilation of extrahepatic bile duct (except retroduodenal portion) and intrahepatic

    biliary radical dilatation.

    Evaluation of Periampullary tumors and portal vein.

    For guiding invasive procedures

    ERCP: procedure of choice In severe acute gallstone pancreatitis Done if there is high likelihood of CBD stones (i.e. Bil. >2mg%, ALP>150U/L,

    present/recent h/o jaundice/ pancreatitis, dilated CBD /stone on sonography) MRCP: a non invasive imaging modality for biliary apparatus

    IOC forpt. with suspected stones having no jaundice, dilated CBD, h/o jaundice or mildgall stone disease.

    PTC: done when USG show dilated intrahepatic ducts, but extrahepatic systemis not dilated or not visualized. Demonstrate nature and site of obstruction

    Decompressive procedures like stenting and biopsies can be done.

    Endoscopic USG: useful to evaluate pancreas, distal bile duct and ampulla. Butit is operator dependent and expensive.

    HIDA scan:for acute/ chronic cholecystitis, bile leak, and iatrogenic biliaryobstruction

    CT scan: earlier considered of no additional help in the diagnosis ormanagement of biliary calculi but now IOC for CBD stones.

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    Investigations Intraoperative cholangiography:

    5-7% of silent CBD stones detected peroperatively

    Reduces CBD injury in approximately 14% of patients

    Lower cost

    Intraoperative choledochoscopy Reduces the incidence of retained or missed stones.

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    Management of gall bladder stones

    Treatment options Surgical - mainstay Medical Lithotripsy

    Cholecystectomy

    Open cholecystectomy Laparoscopic cholecystectomy- gold standard nowIndicationso Symptomatic cholelithiasis: biliary colic, acute cholecystitis, gallstone pancreatitis,

    mucocele, empyema, GB perforation.

    o Acalculous cholecystitis (biliary dyskinesia)

    o Gall bladder dyspepsia (ejection fraction 1 cm in diameter

    o Porcelain gall bladder

    o Asymptomatic cholelithiasis ???

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    Indications of cholecystectomy inasymptomatic gallstones Large stone (>3 cm) [d/t increased risk of malignancy] Multiple small stones [more chances of passing into CBD]

    Stone associated with polyp

    Calcified gall bladder [porcelain gall bladder]

    Congenitally anomalous gall bladder Gall stones with diabetes

    Immunocompromised patients

    Transplant patients [commonly immunocompromised]

    Few authorities are now also recommending routine

    cholecystectomy in all young patients with silent stones [especiallyin areas with high prevalence of carcinoma gall bladder]*

    *Tewari M: Contribution of Silent Gallstones in Gallbladder Cancer. Journal ofSurgical Oncology 2006;93:629632

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    Contraindications of lap. cholecystectomy Absolute Unable to tolerate general anesthesia

    Significant portal hypertension

    Refractory coagulopathy

    Suspicion of gall bladder carcinoma

    Relative Previous upper abdominal surgery

    Cholangitis

    Diffuse peritonitis

    Cirrhosis and / orportal hypertension

    Chronic obstructive pulmonary disease

    Cholesystoenteric fistula

    Morbid obesity

    pregnancy

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    Laparoscopic Cholecystectomy Procedure

    Creation of pneumo - peritoneum

    Port placement

    Dissection of Calots Triangle

    Clipping of cystic duct & cystic A Dissection of Gall bladder

    Extraction of Gall bladder

    Port closure

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    Laparoscopic cholecystectomy*

    Complications of lap. Cholecystectomy

    Advantages Disadvantages

    Less pain

    Smaller incisionBetter cosmesisShorter hospitalizationEarlier return to full activityDecreased total costs

    Lack of depth perception

    View controlled by camera operatorMore difficult to control hemorrhageDecreased tactile discriminationPotential CO insufflation complicationsAdhesions/inflammation limit use

    Slight increase in bile injuries

    HemorrhageBile duct injuryBile leakRetained stonesPancreatitisWound infectionIncisional hernia

    Pneumoperitoneum related CO2 embolism Vaso vagal reflex Cardiac arrhythmias Hypercarbic acidosisTrocar related Abdominal wall bleeding, hematoma Visceral injury Vascular injury

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    Recent advancements in laparoscopiccholecystectomy

    3port laparoscopic cholecystectomy 2 port laparoscopic cholecystectomy Single port laparoscopic cholecystectomy SILS [single incision laparoscopic surgery] / e- NOTES.

    NOTES [natural orifice transluminal endoscopicsurgery] Trans gastric Trans Vaginal Trans anal

    Laparoscopic Assisted Intra Operative UltrasoundGuided Single hole Cholecystectomy (LAIOUSC)

    Robotic Laparoscopic Cholecystectomy

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    Single incision laparoscopic surgery [SILS] Other names: SPA, LESS, OPUS, SPICES, E-NOTES Instruments:

    1. Access ports: SILS device (covidien), gelPOINT (applied medicals), R-Port &triport (advanced surgical concepts), Uni-X (panvel).

    2. Hand instruments: standard or articulat