Single-stage laparoscopic management for concomitant gallstones and common bile duct stones versus...

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  1. 1. Single-stage laparoscopic management for concomitant gallstones and common bile duct stones versus two stages using ERCP procedures By: Mohamed Tag El-Din Mohamed General surgery specialist Qena general hospital
  2. 2. Protocol Submitted for partial fulfillment of Doctor Degree in General surgery Under supervision of Prof. Dr. Alaa Ahmed Redwan Professor of GIT surgery and laparoendoscopy Faculty of medicine, Sohag University Dr. Magdy Khalil Abd El-Mageed Assistant professor of general surgery Faculty of medicine, Sohag University Dr. Ahmed Abd El-Kahaar Aldardeer Lecturer of general surgery Faculty of medicine, Sohag University 2017
  3. 3. Introduction O Gallbladder stone is a common cause for abdominal pain. O Gallstones are rarely an indication for surgery, but 10% of the adult population live with them without any related complications. O Furthermore, 30% of the population over 70 years of age will have gallstone. (Kenny R et al, 2014)
  4. 4. O As many as 35% of patients with gallstones will ultimately become symptomatic and require cholecystectomy. O Gallstones can sometimes migrate out of the gallbladder and become trapped in common bile duct . (Dasari et al, 2013).
  5. 5. O CBD stones is concomitant with gallstones in approximately 3%-10% of the patients. O Between 10% and 18% of people undergoing cholecystectomy for gallstones have common bile duct stones. (Bansal et al, 2014).
  6. 6. Clinical presentation O Stones within the bile duct are often asymptomatic and may be found incidentally, however, more frequently they lead to symptomatic presentation with: o Biliary colic o Ascending cholangitis o Obstructive jaundice o Acute pancreatitis (Bansal et al, 2014).
  7. 7. Radiographic features 1. Ultrasound O Sensitivity has been variably reported between 13-55% . O Findings include: O Visualization of stone O Dilated bile duct (Frank Gaillard et al,2016)
  8. 8. 2. CT abdomen O Sensitivity of 65-88% O Findings include o Target sign: central rounded density stone surrounding lower attenuating bile or mucosa o Rim sign: stone is outlined by thin shell of density o Crescent sign: bile eccentrically outlines luminal stone, creating a low attenuation crescent o Calcification of the stone: unfortunately only 20% of stones are of high density (Frank Gaillard et al,2016)
  9. 9. 3. MRCP O Sensitivity (90-94%) and specificity (95- 99%) O Findings include Filling defects are seen within the biliary tree (Frank Gaillard et al,2016)
  10. 10. Management O In the pre-endoscopy and pre-laparoscope era, the standard treatment for patients suffering from gallstones accompanied with common bile duct stones was open cholecystectomy and common bile duct exploration. (Bansal et al, 2014).
  11. 11. Open exploration of CBD O Kocher incision O Choledochotomy Incision O Exploring the CBD O Extraction of stones O Cholecystectomy O Insertion of the T-Tube O Drainage and Closure (Carol E. H et al, 2013)
  12. 12. ERCP O With all the breakthrough of endoscopic retrograde cholangiopancreatography (ERCP), endoscopic stone removal grew to become the treating preference for removal of CBD stones . O Two-stage management using ERCP accompanied by laparoscopic cholecystectomy is a very common technique for treatment of gall bladder and CBD stones. (Pankaj Prasson et al, 2016).
  13. 13. O ERCP is a procedure that enables to examine the pancreatic and bile ducts. O An endoscope about the thickness of index finger is placed through mouth and into stomach and first part of duodenum. (Pankaj Prasson et al, 2016).
  14. 14. O In the duodenum a small opening is identified (ampulla) and a small plastic tube (cannula) is passed through the endoscope and into this opening. O Dye (contrast material) is injected and X- rays are taken to study the ducts of the pancreas and liver. (Pankaj Prasson et al, 2016).
  15. 15. O Another open channel in the endoscope also allows other instruments to be passed through it in order to perform biopsies, to insert plastic or metal stents or tubing to relieve obstruction of the bile ducts, and to perform incisions by using electrocautery. (Pankaj Prasson et al, 2016).
  16. 16. Laparoscopic exploration of CBD O The laparoscopic common bile duct exploration is a potential option for managing stones within the biliary tree at the same time as laparoscopic cholecystectomy. (Pankaj Prasson et al, 2016).
  17. 17. O The procedure is performed with the patient in the supine position, with the surgeon on the patients right and the assistant on the left. O the laparoscopic monitor are placed at the patients head to the right. (Bansal et al, 2014).
  18. 18. Port sites
  19. 19. The 5.5-mm rigid choledochoscope was inserted through the epigastric port
  20. 20. The bile duct stone was extracted via basket at the direct view.
  21. 21. Use the laparoscopic interrupted sutures to close the choledochotomy.
  22. 22. Aim of Work O The aim of this study is to compare between the outcome of management of concomitant gallstones and common bile duct by two stage (ERCP+LC) versus one stage(LECBD+LC) as regard: Intraoperative complications Conversion to other procedure Total operative time Postoperative complications Postoperative mortality Retained CBD stones Length of hospital stay Patient satisfaction
  23. 23. Patients and Methods O This retrospective and prospective study will include patients with concomitant gallstones and common bile duct in General surgery department in sohag university hospital.
  24. 24. Criteria for inclusion 1. Age 16 to 70 years. 2. Patients with gallbladder stones and concomitant stones in the CBD. 3. Patients with or without Jaundice.
  25. 25. Criteria for exclusion 1. Acute cholecystitis. 2. Acute pancreatitis. 3. Uncorrectable coagulopathy. 4. Liver cirrhosis, mass or abscess. 5. Recurrent choledocholithiasis. 6. Malignant pancreatic or biliary tumors.
  26. 26. Preoperative Preparation 1. Routine investigations in form of: complete blood picture, prothrombin time and concentration, blood glucose, serum creatinine , complete liver functions, serology, blood typing. 2. Radiological investigations in form of abdominal U/S and MRCP. 3. Written informed consent will be taken from all patients.
  27. 27. Operative management O Group I patients underwent single-stage laparoscopic CBD exploration (LCBDE) and laparoscopic cholecystectomy (LC). O Group II patients underwent a two-stage procedure; ERCP for endoscopic extraction of CBD stones followed by LC (ERCP + LC) within the same hospital admission.
  28. 28. Postoperative management O Postoperatively, the patients were followed up at 1 week, 2 weeks, 3 weeks, 6 week, and up to 3months by: O clinically: pain, fever, jaundice, wound condition O laboratory: liver function test O investigatory: abdominal U/S
  29. 29. O At a 6-week follow-up evaluation, overall satisfaction was assessed on a verbal rating scale with scores of 0 (not satisfied), 1 (partially satisfied), 2 (satisfied), or 3 (very satisfied). Primary end point: O Defined as removal of CBD stones and gallbladder by the intended approach
  30. 30. Secondary end points O Intraoperative complications: CBD injury O Operative time in minutes O Postoperative complications: bile leak, hemorrhage, pancreatitis O Pain score: The pain score was calculated on a visual analog scale ranging from 1 to 10.
  31. 31. O Hospital stay: The hospital stay was calculated in group I as the number of days in the hospital after surgery until the patient was discharge and in group II as the total duration of stay for ERCP and cholecystectomy. O Patient satisfaction score: Patient satisfaction was scored on a verbal rating scale with scores of 0 (not satisfied), 1 (partially satisfied), 2 (satisfied), and 3 (very satisfied)