Download - Guidelines Management of Common Bile Duct Stones

040923040923 DRMUHAMMAD ABUKHATERDRMUHAMMAD ABUKHATER 11

Guidelines Guidelines Management of Management of

Common Bile Duct Common Bile Duct Stones Stones

Presented by Presented by DRMUHAMMAD ABUKHATERDRMUHAMMAD ABUKHATER

FRCS IRELAND FRCS IRELAND

21September 2011 21September 2011


Biliary tract stones can be Biliary tract stones can be found in any locationfound in any location



When patients present with CBD When patients present with CBD StoneStone

What is the best modality of treatment

CBDSCBDS

Common bile duct stones (CBDSs) may Common bile duct stones (CBDSs) may occur in up to 3ndash147 of all patients occur in up to 3ndash147 of all patients for whom cholecystectomy is preformedfor whom cholecystectomy is preformed

CBDS have symptomsCBDS have symptoms

It is important to distinguish between It is important to distinguish between

primary and secondary stonesprimary and secondary stones


ERCP with or without endoscopic ERCP with or without endoscopic biliary sphincterotomy biliary sphincterotomy

Laparoscopic CBD exploration Laparoscopic CBD exploration (Transcystic or Transcholedochal)(Transcystic or Transcholedochal)

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



Technical successTechnical success SafetySafety Cost effectivenessCost effectiveness It is the first line investigation in It is the first line investigation in

patients with suspected CBDSpatients with suspected CBDS

Specificity 95

Sensitivity 25 to 63



ERCPERCP

Sensitivity 90 to 95 Specificity 92 to 98

Morbidity rate of 159 and a mortality rate of 1




The Reasons to Perform a The Reasons to Perform a SphincterotomySphincterotomy


Residual or recurrent common bile Residual or recurrent common bile duct stones following duct stones following cholecystectomycholecystectomy

Biliary pancreatitis Biliary pancreatitis Papillary stenosis due to a tumor or Papillary stenosis due to a tumor or

scarring scarring To facilitate the placement of a To facilitate the placement of a

stent stent Common bile duct stones in high-Common bile duct stones in high-

risk surgical patients with intact risk surgical patients with intact gallbladdersgallbladders

MRCPMRCP

Accurate noninvasive diagnostic Accurate noninvasive diagnostic modality for investigating the biliary modality for investigating the biliary ductsducts

Sensitivity of 95 and a specificity of Sensitivity of 95 and a specificity of 9797






What are Diseases What are Diseases Diagnosed by MRCP Diagnosed by MRCP


((MRCPMRCP))

Biliary DiseaseBiliary Disease Cystic disease of bile duct (choledochal cyst choledochocele Carolirsquos Cystic disease of bile duct (choledochal cyst choledochocele Carolirsquos

disease)disease)

Congenital variants (low or medial duct insertion aberrant right hepatic Congenital variants (low or medial duct insertion aberrant right hepatic duct)duct)

CholedocholilithiasisCholedocholilithiasis

Primary sclerosing cholangitisPrimary sclerosing cholangitis

Post-surgical biliary complicationsPost-surgical biliary complications

Cholangiocarcinoma Klatskin Tumor of the Bile Duct Cholangiocarcinoma Klatskin Tumor of the Bile Duct

Pancreatic DiseasePancreatic Disease Pancreas divisumPancreas divisum

Chronic pancreatitisChronic pancreatitis

Pancreatic cancerPancreatic cancer

EUSEUS

Endoscopic insertion of an ultrasound Endoscopic insertion of an ultrasound probe through the stomach and up to the probe through the stomach and up to the second half of the duodenumsecond half of the duodenum

Noninvasive testNoninvasive test Highly dependent on the examinerHighly dependent on the examiner



Sensitivity 95 Specificity 95ndash98


EUSEUS has a high sensitivity and has a high sensitivity and specificity for detection of common specificity for detection of common bile duct stones equal to or better bile duct stones equal to or better than that of (ERCP) without the than that of (ERCP) without the risks of ERCP-related pancreatitis risks of ERCP-related pancreatitis

Laurent Palazzo from the University of ParisLaurent Palazzo from the University of Paris

Conventional Computed Conventional Computed Tomography (CT)Tomography (CT)

Sensitivity of 87 and a specificity of Sensitivity of 87 and a specificity of 97 for the diagnosis of CBD stones97 for the diagnosis of CBD stones

Risk of allergic reaction to contrast Risk of allergic reaction to contrast injection injection


Intraoperative Intraoperative Cholangiography (IOC)Cholangiography (IOC)

Routine use of IOC is still controversialRoutine use of IOC is still controversial Identify choledochal stones Identify choledochal stones Open or laparoscopic cholecystectomyOpen or laparoscopic cholecystectomy Sensitivity of 98 and Specificity of Sensitivity of 98 and Specificity of

9494 Retained stonesRetained stones CBD injuries CBD injuries Operative time Operative time 040923040923 DRMUHAMMAD ABUKHATERDRMUHAMMAD ABUKHATER 2424

Intervention or SurgeryIntervention or Surgery

Today therapeutic decision-making is Today therapeutic decision-making is based on the local availability of based on the local availability of expertiseexpertise

pre- or postoperative ERCP with pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST) endoscopic biliary sphincterotomy (EST) in in aatwo-stage proceduretwo-stage procedure

surgical bile duct clearance and surgical bile duct clearance and cholecystectomy as cholecystectomy as one-stage procedureone-stage procedure


Kharbutli et al reported that Kharbutli et al reported that one-one-stage management stage management of symptomatic of symptomatic CBDS is associated with less CBDS is associated with less morbidity and mortality (7 and morbidity and mortality (7 and 019) 019)

Than Than two-stagetwo-stage management (135 management (135 and 05)and 05)



(ERCP)(ERCP) Endoscopic biliary sphincterotomy Endoscopic biliary sphincterotomy

(EST)(EST) Endoscopic balloon dilation of the Endoscopic balloon dilation of the

papillapapilla Short-term use of a biliary stent Short-term use of a biliary stent



Laparoscopic Common Bile Duct Laparoscopic Common Bile Duct ExplorationExploration

surgical expertisesurgical expertise adequate equipmentadequate equipment

biliary anatomybiliary anatomy number and size of CBD stones number and size of CBD stones

stone clearance rates ranging from stone clearance rates ranging from 85 to 95 a morbidity rate of 4ndash85 to 95 a morbidity rate of 4ndash16 and a mortality rate of around 16 and a mortality rate of around

0ndash20ndash2040923040923 DRMUHAMMAD ABUKHATERDRMUHAMMAD ABUKHATER 2828


Postoperative Evaluation Postoperative Evaluation and Managementand Management

Retained stones are discovered after Retained stones are discovered after an operation (an operation (2525))

laparoscopic or open explorationlaparoscopic or open exploration

Percutaneous transhepatic therapies Percutaneous transhepatic therapies


18891889 1 1stst CBD exploration by Ludwig CBD exploration by Ludwig Courvoisier a Swiss surgeon Courvoisier a Swiss surgeon

ndash Kocherization of duodenum and short longitudinal Kocherization of duodenum and short longitudinal choledochotomycholedochotomy

ndash Stones removed with palpation irrigation with flexible Stones removed with palpation irrigation with flexible catheters forceps catheters forceps

ndash Completion with T-tube drainageCompletion with T-tube drainagendash For many years this was the standard treatment for For many years this was the standard treatment for

cholecystocholedocholithiasischolecystocholedocholithiasis


Open Common Bile Duct Open Common Bile Duct ExplorationExploration

Choledochoenterostomy Choledochoenterostomy CBDgt 2 CMCBDgt 2 CM

A- A- Side-to-side Side-to-side choledochoduodenostomycholedochoduodenostomy

B- B- Choledochojejunostomy with a roux-Choledochojejunostomy with a roux-en-Y en-Y

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SphincterotomySphincterotomy040923040923 DRMUHAMMAD ABUKHATERDRMUHAMMAD ABUKHATER 3232

CBD ExplorationCBD Exploration









1048708Ideal for patient with 1- 3 distal stones1048708Non dilated ducts1048708with or without T- tube insertion

CholedochoduodenostomyCholedochoduodenostomy


1048708 Introduced by Sprengel 1891

1048708 CBD must be gt 2 cm

1048708 Low morbidity and mortality

CholedochojejunostomyCholedochojejunostomy


1048708 Can be performed for CBD lt 2 cm

1048708Following previous open CBD exploration

Transduodenal Transduodenal SphincterotomySphincterotomy

and Sphincteroplastyand Sphincteroplasty


1048708 Used primarily for impacted stones at the ampulla

1048708 Definitive treatment of ampullary stenosis

1048708 Access to pancreatic duct


It should not be forgot that It should not be forgot that the open approach always the open approach always remains as a final option remains as a final option when others modalities have when others modalities have failedfailed


Various Techniques for the Surgical Treatment of Common Bile Duct Stones A Meta Review1Department of Surgery Shariati Hospital Tehran University of Medical Sciences Tehran Iran2Department of General Visceral and Transplantation Surgery University of Heidelberg 69120 Heidelberg Germany


1-Which of the following is single best 1-Which of the following is single best predicting factor for presence of CBD predicting factor for presence of CBD

Stones Stones

A- Alkaline phosphataseA- Alkaline phosphatase B- AST B- AST C- Total bilirubin C- Total bilirubin D- AmylaseD- Amylase


2- CBD stones found in a patient one 2- CBD stones found in a patient one year after cholecystectomy are most year after cholecystectomy are most

likelylikely

A- Retained B- Recurrent C- Primary D- b and c


3- When sphincterotomy or papillotomy are unsuccessful the surgeon can perform

which of the following for proper drainage of CBD stones

A Choledochotomy and stone retrieval

b Transduodenal sphincteroplasty c Choledochoduodenostomy d Choledochojejunostomy e All of the above


4- When the ampulla is exposed through duodenal access what is the

preferred incision for access to the CBD

A 5 orsquo clock b 3 orsquoclock c 11 orsquoclock d 2 orsquoclock e 12 orsquoclock



March 25 2008 mdash March 25 2008 mdash New New guidelines issued for guidelines issued for management of common bile management of common bile duct stonesduct stones (CBDS) have been (CBDS) have been published in the March 5 Online published in the March 5 Online First issue of First issue of GutGut


The British Society of The British Society of GastroenterologyGastroenterology ((BSGBSG) ) commissioned these guidelines commissioned these guidelines which were subsequently reviewed which were subsequently reviewed revised and endorsed by the revised and endorsed by the Clinical Standards and Services Clinical Standards and Services CommitteeCommittee of the BSG the BSG of the BSG the BSG Endoscopy Committee the ERCP Endoscopy Committee the ERCP stakeholder group the Association stakeholder group the Association of Upper Gastrointestinal Surgeons of Upper Gastrointestinal Surgeons of Great Britain and Ireland and the of Great Britain and Ireland and the Royal College of RadiologistsRoyal College of Radiologists


After a preliminary search of the After a preliminary search of the literature in 2004 of PubMed and literature in 2004 of PubMed and MEDLINE the findings were summarized MEDLINE the findings were summarized and were presented to the and were presented to the British British Society of GastroenterologySociety of Gastroenterology (BSG)(BSG) Endoscopy Committee which developed Endoscopy Committee which developed principal clinical questions to be principal clinical questions to be addressed by the guidelinesaddressed by the guidelines

A multidisciplinary guideline-writing A multidisciplinary guideline-writing group then wrote provisional guidelinesgroup then wrote provisional guidelines


Some of the specific Some of the specific recommendations are as followsrecommendations are as follows

Hepatobiliary cases should be Hepatobiliary cases should be discussed in a multidisciplinary discussed in a multidisciplinary setting (grade C)setting (grade C)

Symptomatic patients in whom Symptomatic patients in whom

evaluation suggests ductal stones evaluation suggests ductal stones should undergo extraction if possible should undergo extraction if possible (grade B)(grade B)


Transabdominal ultrasound scanning Transabdominal ultrasound scanning (USS) is recommended as a (USS) is recommended as a preliminary investigation for CBDS preliminary investigation for CBDS but it is not a sensitive test for this but it is not a sensitive test for this condition (grade B) condition (grade B)

EUS and MR cholangiography are both EUS and MR cholangiography are both highly effective at confirming CBDS highly effective at confirming CBDS patient suitability accessibility and patient suitability accessibility and local expertise should help decide local expertise should help decide between the 2 procedures (grade B)between the 2 procedures (grade B)


When performing endoscopic stone When performing endoscopic stone extraction (ESE) the endoscopist extraction (ESE) the endoscopist should be assisted by a technician or should be assisted by a technician or radiologist who can help with radiologist who can help with fluoroscopy a nurse for safety fluoroscopy a nurse for safety monitoring and an additional monitoring and an additional endoscopy assistant or nurse to endoscopy assistant or nurse to manage guide wires and other manage guide wires and other technical aspects as needed (grade technical aspects as needed (grade C)C)


ERCP should be done only in ERCP should be done only in patients who are expected to patients who are expected to require an intervention it is not require an intervention it is not recommended for use solely as a recommended for use solely as a diagnostic test (grade B)diagnostic test (grade B)


Full blood count and prothrombin Full blood count and prothrombin timeinternational normalized ratio timeinternational normalized ratio (PTINR) should be performed within (PTINR) should be performed within 72 hours before biliary 72 hours before biliary sphincterotomy for ductal stones sphincterotomy for ductal stones patients with abnormal clotting patients with abnormal clotting should undergo subsequent should undergo subsequent management based on locally agreed management based on locally agreed guidelines (grade B)guidelines (grade B)


For patients treated with anticoagulants For patients treated with anticoagulants but who are at low risk for but who are at low risk for thromboembolism anticoagulants should thromboembolism anticoagulants should be discontinued before endoscopic stone be discontinued before endoscopic stone extraction if biliary sphincterotomy is extraction if biliary sphincterotomy is planned (grade B) as should newer planned (grade B) as should newer antiplatelet agents (eg clopidogrel) 7 to antiplatelet agents (eg clopidogrel) 7 to 10 days before biliary sphincterotomy 10 days before biliary sphincterotomy (grade C) Use of aspirin nonsteroidal anti-(grade C) Use of aspirin nonsteroidal anti-inflammatory drugs (NSAIDs) and low-dose inflammatory drugs (NSAIDs) and low-dose heparin should not be considered a heparin should not be considered a contraindication to biliary sphincterotomy contraindication to biliary sphincterotomy (grade B)(grade B)


Patients with biliary obstruction Patients with biliary obstruction or previous features of biliary or previous features of biliary sepsis should receive sepsis should receive prophylactic antibiotics (grade prophylactic antibiotics (grade A)A)


Sphincterotomy initiated with use Sphincterotomy initiated with use of pure cut may be preferred in of pure cut may be preferred in patients with risk factors for post-patients with risk factors for post-ERCP pancreatitis but not biliary ERCP pancreatitis but not biliary sphincterotomyndashinduced sphincterotomyndashinduced hemorrhage (grade A) hemorrhage (grade A)


In most patients undergoing stone In most patients undergoing stone extraction balloon dilation of the extraction balloon dilation of the papilla should be avoided because papilla should be avoided because the risk for severe post-ERCP the risk for severe post-ERCP pancreatitis is increased vs biliary pancreatitis is increased vs biliary sphincterotomy (grade A)sphincterotomy (grade A)


Short-term use of a biliary stent Short-term use of a biliary stent followed by further endoscopy or followed by further endoscopy or surgery is recommended to surgery is recommended to ensure adequate biliary drainage ensure adequate biliary drainage in patients with CBDS that have in patients with CBDS that have not been extracted (grade B)not been extracted (grade B)


Use of a biliary stent as sole Use of a biliary stent as sole treatment of CBDS should be treatment of CBDS should be limited to patients with limited limited to patients with limited life expectancy or prohibitive life expectancy or prohibitive surgical risk or both (grade A)surgical risk or both (grade A)


Pre-cut is a risk factor for Pre-cut is a risk factor for complication and should be used complication and should be used only by those with appropriate only by those with appropriate training and experience and only training and experience and only in patients for whom subsequent in patients for whom subsequent endoscopic treatment is endoscopic treatment is essential (grade B)essential (grade B)


Operative risk should be Operative risk should be evaluated before scheduling evaluated before scheduling intervention and endoscopic intervention and endoscopic therapy should be considered as therapy should be considered as an alternative in high-risk an alternative in high-risk patients (grade B)patients (grade B)


Intraoperative cholangiography Intraoperative cholangiography or laparoscopic ultrasound can or laparoscopic ultrasound can detect CBDS in patients who are detect CBDS in patients who are suitable for surgical exploration suitable for surgical exploration or postoperative ERCP (grade B)or postoperative ERCP (grade B)


In patients undergoing laparoscopic In patients undergoing laparoscopic cholecystectomy transcystic and cholecystectomy transcystic and transductal exploration of the transductal exploration of the common bile duct are both common bile duct are both considered appropriate for removal considered appropriate for removal of CBDS (grade A)of CBDS (grade A)


When minimally invasive When minimally invasive techniques fail to achieve duct techniques fail to achieve duct clearance open surgical clearance open surgical exploration is still considered to exploration is still considered to be an important treatment be an important treatment option (grade B)option (grade B)


` The guidelines also discuss supplementary The guidelines also discuss supplementary

treatments includingtreatments including

- Mechanical lithotripsy - Mechanical lithotripsy

- Extracorporeal shock wave lithotripsy- Extracorporeal shock wave lithotripsy

- Electrohydraulic lithotripsy- Electrohydraulic lithotripsy

- Laser lithotripsy- Laser lithotripsy

- Percutaneous treatment- Percutaneous treatment

- Oral ursodeoxycholic acid- Oral ursodeoxycholic acid

- Management of specific clinical scenarios - Management of specific clinical scenarios isis

also presentedalso presented


Biliary sphincterotomy and Biliary sphincterotomy and endoscopic stone extraction endoscopic stone extraction (ESE) is recommended as the (ESE) is recommended as the primary form of treatment for primary form of treatment for patients with CBDS post patients with CBDS post cholecystectomycholecystectomy


The authors of the guidelines The authors of the guidelines write Cholecystectomy is write Cholecystectomy is recommended for all patients recommended for all patients with CBDS and symptomatic with CBDS and symptomatic gallbladder stones unless there gallbladder stones unless there are specific reasons for are specific reasons for considering surgery considering surgery inappropriate inappropriate


Patients with CBDS undergoing Patients with CBDS undergoing laparoscopic cholecystectomy may laparoscopic cholecystectomy may be managed by laparoscopic be managed by laparoscopic common bile duct exploration common bile duct exploration (LCBDE) at the time of surgery or (LCBDE) at the time of surgery or undergo peri-operative ERCPundergo peri-operative ERCP



Based on the BSG guidelines which of Based on the BSG guidelines which of the following statements about the following statements about evaluation of CBDS is evaluation of CBDS is correctcorrect

Transabdominal USS is a sensitive test Transabdominal USS is a sensitive test for CBDSfor CBDS

EUS is significantly less effective than EUS is significantly less effective than MR cholangiography for confirming MR cholangiography for confirming CBDSCBDS

EUS is significantly more effective than EUS is significantly more effective than MR cholangiography for confirming MR cholangiography for confirming CBDSCBDS

Transabdominal USS is recommended Transabdominal USS is recommended as a preliminary investigation for CBDSas a preliminary investigation for CBDS


Based on the BSG guidelines which Based on the BSG guidelines which of the following statements about of the following statements about

treatment of CBDS is treatment of CBDS is notnot correct correct Perioperative ERCP is not recommended for patients Perioperative ERCP is not recommended for patients

with CBDS undergoing laparoscopic with CBDS undergoing laparoscopic cholecystectomycholecystectomy

Biliary sphincterotomy and endoscopic stone Biliary sphincterotomy and endoscopic stone extraction (ESE) are recommended as the primary extraction (ESE) are recommended as the primary forms of treatment of patients with CBDS forms of treatment of patients with CBDS postcholecystectomypostcholecystectomy

Cholecystectomy is recommended for all patients Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones with CBDS and symptomatic gallbladder stones unless they are not surgical candidatesunless they are not surgical candidates

Patients with CBDS undergoing laparoscopic Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by laparoscopic cholecystectomy may be treated by laparoscopic common bile duct exploration (LCBDE) at the time common bile duct exploration (LCBDE) at the time of surgeryof surgery


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Specificity 95




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