current trends in management of choledocholithiasis
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CURRENT TRENDS IN MANAGEMENT OF
CHOLEDOCHOLITHIASIS
S.K. SAHU
MODERATOR –
DR A. SILODIA
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INTRODUCTION – CBD stones
Present in 10 – 15 % of cholecystectomy pts
Incidence rises with age, duration of gallstone symptoms
Associated with high rate of complications
Should always be removed
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CLASSIFICATION – CBD Stones
By the point of origin1. Primary CBD Stones2. Secondary CBD Stones
By the time of discovery relative to cholecystectomy
1. Retained 2. Recurrent
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PRESENTATION – CBD Stones
Biliary colic Jaundice Pale stools Darkening of urine Fever with chills – cholangitis Charcots triad, Reynolds pentad
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LABORATORY INVESTIGATIONS
Elevated s. bilirubin,aminotransferase, alkaline phosphatase
May be normal in 1/3 of patients with CBD Stones
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DIAGNOSING CBD STONES
USG– decreased sensitivity– retro and intraduodenal stones not visualized
EUS– increased sensitivity
ERCP– added advantage of being therapeutic in distal
stones
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DIAGNOSING CBD STONES
MRCP not a therapeutic procedure does not have morbidity and mortality
associated with ERCP may avoid use of unnecessary invasive
procedures
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Indications of MRCP
unsuccessful or contraindicated ERCP patient preference for non-invasive imaging patients considered to be at low risk of
having pancreatic or biliary disease; patients where need for therapeutic ERCP is
unlikely with a suspected neoplastic cause for
pancreatic or biliary obstruction
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CBD Stone on USG
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CBD Stone on EUS
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CBD Stone on MRCP
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CBD Stone on IOC
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MANAGEMENT – CBD Stones
Open cholecystectomy + surgical exploration of the CBD – in the past/ centres where laparoscopy not available
ERCP + Endoscopic Sphincterotomy followed by cholecystectomy – most frequently used
Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in experienced hands
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OPEN CBD EXPLORATION
Time tested method
Indicated if1. Stones detected during open
cholecystectomy2. Need for biliary enteric anastamosis3. Endoscopy difficult / risky4. Unsuccessful LCBDE5. Impacted/ multiple / larger stones
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OPEN CBD EXPLORATION
Contraindicated in
1. Small CBD <5mm
2. Portal HT
3. Severe periportal inflammation
4. Cholangitis with septic shock
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ERCP + ES - Indications
CBD Stones detected prior to cholecystectomy
High risk patients unfit for operation
Severe cholangitis / pancreatitis
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CBD Stone on ERCP
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ERCP + ES - complications
Pancreatitis(7%) Cholangitis Bleeding (2%) Perforation Abscess, recurrence Duodenobiliary reflux Rarely death
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ERCP +ES - Limitations
Operator dependent
Cost & need for 2nd stage – a concern
Positive ERCP in only 34 % of cases
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ADJUVANT TECHNIQUES with ERCP +ES
Mechanical lithotripsy
LASER lithotripsy
Electrohydraulic lithotripsy
ESWL
Chemical contact dissolution therapy
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ADJUVANT TECHNIQUES - indications
Stones larger than the endoscope
Shape square/ piston shaped / faceted
Tightly packed stones/ hard stones
Intrahepatic stones
Stones proximal to CBD stricture
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Laparoscopic CBD Exploration (LCBDE)
Components Laparoscopic cholecystectomy
Intraoperative cholangiography
Exploration if stone detected
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LCBDE - Indications
Abnormal intraoperative cholangiogram or sonogram
Scintigraphic / endoscopic / radiographic evidence of bile duct stones
History of biliary pancreatitis
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LCBDE - contraindications
Coagulopathy
Local porta pathology
Inability of surgeon to do LCBDE
Unfit patient
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LCBDE - Approach
Transcystic
Choledochotomy
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Transcystic LCBDE
Preferred approach Easy, more physiological Cystic duct should join CHD laterally or
posteriorly Indicated in small (<6mm), limited no of
stones(<5),absence of CHD stones
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Laparoscopic choledochotomy
Used if cystic duct cant be dilated / intrahepatic pathology
Indicated in large (>6mm), more than 5 stones, CHD stones
Spiral course of cystic duct/ medial opening of cystic duct is an indication
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LCBDE - advantages
Single admission/ short hospital stay
Reduced morbidity/ mortality
Success rate comparable to ERCP +ES
Failed LCBDE can be converted to open in the same sitting
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LCBDE - limitations
Increased operative time / cost
Expertise not commonly available
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SUSPECTED CBD Stones
jaundice No jaundice
Severe comorbidity Fit for surg
ERCP+ES
No further action
Lap chole+IOC
Stones
Operative removal
Post op ERCP
FailureThen choledochoduodenostomy
Failure thenRepeat surgery
MRCP
STONES present No stones
Lap choleunfit fit
Chole +ECBDERCP
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CONCLUSION
CBD Stones associated in 10 – 15 % pts undergoing cholecystectomy
Advanced endoscopic & laparoscopic techniques have revolutionised management
Treatment depends on resources, technical limitations, surgeons expertise
LCBDE is safe, feasible, single stage management option for CBD stones
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THANK YOU