management of concomitant gallbladder and common bile duct stones joint hospital surgical grand...
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Management of Concomitant Gallbladder Management of Concomitant Gallbladder and Common Bile Duct Stonesand Common Bile Duct Stones
Joint Hospital Surgical Grand RoundJoint Hospital Surgical Grand Round
19th October 201319th October 2013
Dr. Wong Chun LamDr. Wong Chun Lam
Pamela Youde Nethersole Eastern HospitalPamela Youde Nethersole Eastern Hospital
Hong Kong SARHong Kong SAR
BackgroundBackground
10-18% of patients with gallbladder stones harbor common bile duct 10-18% of patients with gallbladder stones harbor common bile duct stonesstones
Before development of laparoscopyBefore development of laparoscopy Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with
open cholecystectomyopen cholecystectomy Open cholecystectomy with exploration of common bile ductOpen cholecystectomy with exploration of common bile duct Open cholecystectomy with post-operative ERCPOpen cholecystectomy with post-operative ERCP
With advancement in laparoscopic surgeryWith advancement in laparoscopic surgery
Laparoscopic cholecystectomy (LC) + CBD exploration Laparoscopic cholecystectomy (LC) + CBD exploration (LCBDE)(LCBDE)
LC + Intra-operative ERCPLC + Intra-operative ERCP LC + Open cholecystectomyLC + Open cholecystectomy Pre-operative ERCP + LCPre-operative ERCP + LC LC + Post-operative ERCPLC + Post-operative ERCP
Factors affecting choice
Patient’s general conditionPatient’s general condition Previous operationPrevious operation Stone’s characteristics (size, number, location)Stone’s characteristics (size, number, location) Anatomy of biliary treeAnatomy of biliary tree Timing of discovery of CBD stonesTiming of discovery of CBD stones FacilitiesFacilities Expertise in laparoscopic surgery / ERCPExpertise in laparoscopic surgery / ERCP
Pre-operative ERCP + LCPre-operative ERCP + LC
Patient presenting with obstructive jaundice / cholangitis Patient presenting with obstructive jaundice / cholangitis / severe pancreatitis/ severe pancreatitis ERCP ERCP initial therapeutic procedure initial therapeutic procedure Followed by lap. cholecystectomy after condition improvedFollowed by lap. cholecystectomy after condition improved
AdvantageAdvantage Technical skill not demandingTechnical skill not demanding Minimizes operation timeMinimizes operation time
DisadvantageDisadvantage Two-stage procedureTwo-stage procedure Possible septic complications between two Possible septic complications between two
proceduresprocedures
LC + Laparoscopic CBD exploration LC + Laparoscopic CBD exploration (LCBDE)(LCBDE)
Failed endoscopic removal of CBD stonesFailed endoscopic removal of CBD stones CBD stones difficult for endoscopic removalCBD stones difficult for endoscopic removal
History of gastrectomyHistory of gastrectomy Multiple CBD stonesMultiple CBD stones Large CBD stonesLarge CBD stones
Advantage:Advantage: Single-stage procedureSingle-stage procedure
Disadvantage:Disadvantage: Technically demandingTechnically demanding Risks of bile duct complicationsRisks of bile duct complications
LCBDE (Transcystic approach)LCBDE (Transcystic approach)
Cystic duct is dilatedCystic duct is dilated
Balloon / flexible basket / choledochoscope through cystic duct to CBD Balloon / flexible basket / choledochoscope through cystic duct to CBD for stone retrieval for stone retrieval
Cystic duct closed with clips / suturesCystic duct closed with clips / sutures
ContraindicationsContraindications Biliary stones proximal to cystic duct junctionBiliary stones proximal to cystic duct junction Small cystic ductSmall cystic duct Spiral shape of cystic ductSpiral shape of cystic duct Large stonesLarge stones Multiple stonesMultiple stones
LCBDE (Choledochotomy)LCBDE (Choledochotomy) Longitudinal incision at anterior surface of CBDLongitudinal incision at anterior surface of CBD
Instruments inserted directly CBD to extract stonesInstruments inserted directly CBD to extract stones Electrohydraulic / Laser lithotripsyElectrohydraulic / Laser lithotripsy
Closure of CBD with sutures +/- placement of T-tubeClosure of CBD with sutures +/- placement of T-tube
IndicationsIndications Large stonesLarge stones Multiple stonesMultiple stones Ductal stones proximal to cystic duct junctionDuctal stones proximal to cystic duct junction
DisadvantageDisadvantage Technically demandingTechnically demanding Risk of bile duct stricture and bile leakRisk of bile duct stricture and bile leak
ContraindicationsContraindications CBD not dilatedCBD not dilated
On-table ERCPOn-table ERCP
Rendezvous techniqueRendezvous technique Guidewire inserted through cystic duct into duodenumGuidewire inserted through cystic duct into duodenum Guidewire caught by duodenoscopeGuidewire caught by duodenoscope Papillotome inserted over guidewire to facilitate CBD cannulationPapillotome inserted over guidewire to facilitate CBD cannulation
Advantage:Advantage: Single-stage procedureSingle-stage procedure 100% cannulation rate100% cannulation rate
Disadvantage:Disadvantage: Supine positioning may cause ERCP more difficultSupine positioning may cause ERCP more difficult Longer operation timeLonger operation time Stones may not be able to clear in one goStones may not be able to clear in one go Requires ERCP endoscopist / staff / equipments in operating Requires ERCP endoscopist / staff / equipments in operating
theatretheatre
Post-operative ERCPPost-operative ERCP
CBD stones noted intra-operativelyCBD stones noted intra-operatively Non dilated CBDNon dilated CBD No expertise in LCBDENo expertise in LCBDE
AdvantageAdvantage Technically not demandingTechnically not demanding
DisadvantageDisadvantage Two-stage procedureTwo-stage procedure Need another operation (CBD exploration) in case of failureNeed another operation (CBD exploration) in case of failure Increased hospital stay and costIncreased hospital stay and cost
Current EvidenceCurrent Evidence
Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + LCBDELC + LCBDE
112 patients with radiological / biochemical evidence of possible 112 patients with radiological / biochemical evidence of possible CBD stonesCBD stones
Pre-op ERCP + Pre-op ERCP + LCLC
(n=55)(n=55)
LC + IOC +/- LC + IOC +/- LCBDELCBDE
(n=57)(n=57)
P-valueP-value
CBD stone CBD stone detecteddetected
3131 1717 0.0070.007
CBD stone CBD stone clearedcleared
30 (98%)30 (98%) 15 (88%)15 (88%) 0.280.28
MorbidityMorbidity 9.1%9.1% 10.5%10.5% >0.99>0.99
MortalityMortality 0%0% 0%0% >0.99>0.99
Hospital stayHospital stay 6.6 days6.6 days 5.3 days5.3 days <0.05<0.05
Rogers SJ et al. Arch Surg 2010; 145(1):28-33. (US)
30 patients with GB stones and CBD stones confirmed on EUS / MRCP30 patients with GB stones and CBD stones confirmed on EUS / MRCP
Pre-op ERCP Pre-op ERCP + LC+ LC
(n=15)(n=15)
LC + LCBDELC + LCBDE
(n=15)(n=15)
P-valueP-value
CBD clearanceCBD clearance 86.7%86.7% 93.5%93.5% >0.05>0.05
MorbidityMorbidity 15.3%15.3% 13.3%13.3% >0.05>0.05
MortalityMortality 0%0% 0%0% >0.05>0.05
Hospital stayHospital stay 4 days4 days 4.2 days4.2 days >0.05>0.05
Bansal VK et al. Surg Endosc 2010; 24: 1986-1989. (India)
Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + LCBDELC + LCBDE
Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + on-table ERCPLC + on-table ERCP
91 patients with GB and CBD stones diagnosed by MRCP91 patients with GB and CBD stones diagnosed by MRCP
Pre-op ERCP Pre-op ERCP + LC+ LC
LC + on-table LC + on-table ERCPERCP
P-valueP-value
CBD clearanceCBD clearance 80%80% 95.6%95.6% >0.05>0.05
PancreatitisPancreatitis 0%0% 2.2%2.2% >0.05>0.05
MorbidityMorbidity 8.8%8.8% 6.5%6.5% >0.05>0.05
Mean hospital Mean hospital staystay
8 days8 days 4.3 days4.3 days <0.0001<0.0001
Total costTotal cost £3834£3834 £2829£2829 <0.05<0.05
Morino M et al. Ann Surg 2006; 244: 889-893. (Italy)
Pre-op ERCP + LCPre-op ERCP + LC vs vs LC + on-table ERCPLC + on-table ERCP
Pre-op ERCP + Pre-op ERCP + LCLC
LC + on-table LC + on-table ERCPERCP
P-valueP-value
CBD clearanceCBD clearance 96.6%96.6% 90.2%90.2% >0.05>0.05
PancreatitisPancreatitis 12.7%12.7% 1.7%1.7% <0.05<0.05
MorbidityMorbidity 23%23% 8.5%8.5% <0.05<0.05
Mean hospital Mean hospital staystay
8 days8 days 5 days5 days <0.05<0.05
Total costTotal cost £2708£2708 £2414£2414 <0.05<0.05
Rabago LR et al. Endoscopy 2006; 38: 779-786. (Spain)
LC + LCBDELC + LCBDE vs vs post-op ERCPpost-op ERCP
LC + LCBDELC + LCBDE
(n=40)(n=40)
LC + Post-op ERCPLC + Post-op ERCP
(n=40)(n=40)
P-valueP-value
Stone Stone clearanceclearance
30 (75%)30 (75%) 30 (75%)30 (75%) >0.05>0.05
MorbidityMorbidity (17.5%)(17.5%) (15%)(15%) >0.05>0.05
MortalityMortality 00 00
Hospital stayHospital stay 1 days1 days 3.5 days3.5 days <0.05<0.05
80 patients noted to have CBD stones in operative cholangiogram 80 patients noted to have CBD stones in operative cholangiogram during lap. cholecystectomyduring lap. cholecystectomy
Rhodes et al. Lancet 1998; 351: 159-161. (UK)
LC + LCBDELC + LCBDE vs vs post-op ERCPpost-op ERCP 372 patients undergoing LC for symptomatic gallstones noted to have CBD 372 patients undergoing LC for symptomatic gallstones noted to have CBD
stones by transcystic cholangiographystones by transcystic cholangiography 286 patients achieved CBD clearance with transcystic approach286 patients achieved CBD clearance with transcystic approach Remaining 86 patients in which transcystic clearance was failedRemaining 86 patients in which transcystic clearance was failed
LC + LCBDELC + LCBDE
(n=41)(n=41)
LC + Post-op ERCPLC + Post-op ERCP
(n=45)(n=45)
P-valueP-value
Stone clearanceStone clearance 40 (97.6%)40 (97.6%) 43 (95.6%)43 (95.6%) >0.05>0.05
Severe Severe pancreatitispancreatitis
1 (2.4%)1 (2.4%) 1 (2.2%)1 (2.2%) >0.05>0.05
MorbidityMorbidity 7 (17%)7 (17%) 6 (13%)6 (13%) >0.05>0.05
Hospital stayHospital stay 6.6 days6.6 days 7.4 days7.4 days >0.05>0.05
Nathanson LK et al. Ann Surg 2005; 242: 188-192. (Australia)
ConclusionConclusion
Comparable stone clearance rate and morbidity between Comparable stone clearance rate and morbidity between all optionsall options
Single-stage proceduresSingle-stage procedures Potential benefit of reducing hospital stay / costPotential benefit of reducing hospital stay / cost Technically demandingTechnically demanding
Depends on patient conditions, stone characteristics, Depends on patient conditions, stone characteristics, facilities and expertisefacilities and expertise
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