recent management of calculous biliary disease

8/7/2019 recent management of calculous biliary disease

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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 articulating

Advantages

reduced postoperative pain. Faster return to normal function.

Reduced port site complications.

Improved cosmesis (scarless surgery).

Patient satisfaction.

Disadvantages Conflict between operative instruments and camera. Smaller degree of instrument triangulation compared to conventional

laparoscopic surgery.

Longer operative time.


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Natural Orifice Trans luminal Endoscopicsurgery NOTES

- Trans Gastric

By double channel flexible endoscope through mouth

Pneumo peritoneum created & Laparoscope introduced

Gastric incision made under vision

Cholecystectomyperformed

Gastrotomy closed from inside by clips

- Trans vaginal- Trans anal


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LAIOUSC Laparoscopic Assisted Intra

Operative Ultrasound Guided Single holeCholecystectomy Single hole made in upper abdomen Laparoscope is used as & when required No gas is used Ultrasound probe is used to identify the structures Claimed as safe due to 3 D view, being gasless and

advantage of Sight & Touch


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Robotic Laparoscopic Cholecystectomy

3 arm robot is used

One arm camera arm

Two arms instrument arms

Two different Surgeons perform Safe & effective in children

Excellent for teaching robotic Surgery

Very useful in complicated Hepato biliary Surgery


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What is the place of open Cholecystectomy ingallstone disease?

Always convert Laparoscopic surgery when needed

Gangrenous Cholecystectomy

Empyema gall bladder

Dense intra peritoneal adhesions Cirrhosis of liver

Cholidocholithiasis

Acute Cholecystitis

Multiple previous upper abdominal surgeries


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Medical therapy 2 bile acids

Chenodeoxycholic acid

Ursodeoxycholic acid (8-10 mg / kg / dayPO divided BD / TDS X 6-18 months)

MOI: inhibits HMG-CoA reductase- reduces cholesterol saturation of bile

Prerequisites:

Radioluscent stones

Size


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Holmium Laser Lithotripsy Non invasive

Extra corporeal shock wave

Fragments stone irrespective of composition

Stone Broken in smallerpieces

Can be combined with oral therapy Used in functional gall bladder

Effective in secondary and primary intra hepatic stones


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Management of CBD stones Depends On

Age

Comorbid factors

Asso. Conditions

Local factors

Availability of facilities

Experience of surgeon.

Treatment options

1. Stone dissolutions

2. Endoscopic management

3. Surgery

4. Alternate therapeutic options: biliary lithotripsy, percutaneoustranshepatic stone extraction


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Treatment options Stone dissolution Methyl t- butyl ether (MTBE) and glyceryl mono octanoate (GMOC)

Given through T- Tube/ nasobiliary catheter

Only for small, single / few cholesterol stones. Not forpigment stones.

Endoscopic management:stent in CBD/ sphinterotomy/ extractionof stones. High success rates of 88.4%, mortality of 1.5%,complication rate of 6-10% [blomgart].

Advantages:

Can be done as elective procedure or emergencyprocedure

Can be done in patients unfit for major surgery

Can be done in patients with complications (jaundice, pancreatitis)

Disadvantages:

Large stones (>1.5 cm), dilated duct (>1 cm), stricture distal to stone, anatomicalabnormalities- these things can cause difficulties


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Treatment options (contd.) Indications of endoscopic management (blomgart, 3rd e) Acute suppurative cholangitis irrespective of gall bladder status

Acute severe gallstone pancreatitis

Obstructive jaundice due to unequivocal evidence of CBD stones andlaparoscopic CBD exploration facility is not available

Post cholecystectomy, retained stones, earlypresentation

Post cholecystectomy, recurrent stones, late presentation Elderlypatient with poor surgical risk where this may be the only intervention

offered.

Techniques used: Dormia type basket

Fogarty type balloon

Mechanical lithotripsy

Laser lithotripsy

Electrohydraulic lithotripsy

Extra corporeal shock wave lithotripsy

Dissolution therapy (MTBE)


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Treatment options (contd.) Surgery

1. Choledocholithotomy: open/ laparoscopic

2. Bilioenteric drainage procedures: open/ laparoscopic

Choledochoduodenostomy

Choledochojejunostomy

Hepaticojejunostomy

3. Hepatectomy


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Treatment options According to clinical situations

1. Gall bladder stones and CBD stones Surgery [open/laparoscopic] Endoscopic sphincterotomy and stone extraction alone Endoscopic sphincterotomy followed by elective cholcystectomy

2. CBD stones with previous cholecystectomy a no T tube Stone dissolution

Surgery Endoscopic sphincterotomy and stone extraction Endoscopic sphincterotomy without stone extraction

3. CBD stone with previous cholecystectomy and T tube Surgery Endoscopic sphincterotomy Dissolution/ extraction using the T- Tube tract


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Laparoscopic CBD exploration (LCBDE)2 approaches1. Trans cystic approach (through cystic duct): require no ductal

manipulation or drainage procedure. Does not risk biliarystricture or leak and is associated with very short hospitalization.

Limitations

Cystic duct size (can be dilated using balloon) Tortuous cystic cystic duct

Large stones >1 cm

Difficult in stones of upper ductal system

2. Choledochotomy: requires closure of duct overT tube orprimary

closure of duct with or with out biliary stent placed in ante gradefashion.

Transcystic approach is preferred as initial approach andcholedochotomy performed when it fails or appears futile


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Role of open CBD exploration Patients with complicated gall stone disease are submitted directly

to open cholecystectomy and CBD exploration.

Indications for CBD exploration duringcholecystectomy

1. Palpable stones in CBD2. Jaundice and cholangitis

3. Stone visualized at intraoperative cholangiography

Post exploratory choledochoscopy and cholangiography are

mandatory in all patients following exploration of CBD. (blomgart,3rd/e)


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Indications for bilioenteric drainageprocedure

Multiple duct stones particularly in dilated ducts in elderly .

One or several large stone within a dilated duct (>1.5 cm)

Irretrievable intrahepatic stones

Proven ampullary stenosis

Impacted ampullary stone

Foryoung, low risk patient, with CBD


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Post cholecystectomy choledocholithiasis Retained stones Recurrent stones

Management of Retained stones in presence of TTube

Observation:if no biliary obstruction or infection. For 4-6 weeks. 10-25%can be expected to pass spontaneously.

Mechanical extraction trough T tube: if stone persists for >4-6 weeks.Success rate 95%, morbidity only 4%

Endoscopic sphincterotomy: reserved for clinically unstable patients orwhen mechanical extraction failed.

Chemical dissolution: rarely indicated

Management of retained/ recurrent stones in absence of T-tube

Endoscopic sphinterotomy is procedure of choice (success rate >85%)

If fails, re exploration of CBD with T-Tube or biliary enteric drainageprocedure.


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Intrahepatic stones

Incidence :0.5% in US, 10% in Asia

Usually associated with extrahepatic CBD stones, Carolis disease,impacted behind stenosis d/t iatrogenic / neoplastic / congenital factors,asiatic cholangiohepatitis / recurrent pyogenic cholangitis.

Predilection to left ductal system.

Management:

CBD Exploration and thorough cleansing of all stones from intrahepatic biliarysystem. (operative choledochoscopy is virtually mandatory)

Multiple intrahepatic stones requires biliary enteric anastomosis (other end fromRoux-en-Y hepaticojejunostomy brought out to the skin to permit furthermanipulations)

Resection of affected liver segment: when severe localized disease, stones cantbe removed, superimposed abscess.


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ComplicationsComplications of endoscopic sphinterotomy (8%) Bleeding (3%)

Duodenal perforation (1%)

Pancreatitis (2%)

Papillary stenosis (delayed) 10-33%

Complications of CBD exploration

Bile leakage

Bile duct stricture (more common in CBD


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recent management of calculous biliary disease

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