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cbd medical procedure

Cbd medical procedure

LCBDE The successful laparoscopic management of CBDS is dependent on several factors including surgical expertise , adequate equipment, the biliary anatomy and the number and size of CBD stones. Successful stone clearance rates for LCBDE range from 85% to 95% with a morbidity rate of 4% to 16% and mortality of 0% to 2% [9].Complications include bile leak and CBD stricture.A metanalysis of 1762 patients who underwent LCBDE from 19 studies worldwide showed a mean duct clearance of 80% with average morbidity of <10% (4–16%) and mortality of <1% (0–2.7%) [10].Also, Transcystic stone clearance may have a recovery very similar to laparoscopic cholecystectomy alone [11, 12] as it is a more anatomical approach. A meta analysis by Guruswamy K.S , Samraj K. in 2007 showed no statistically significant difference in any of the out comes between T-tube and primary closure of choledochotomy, apart from the hospital stay which was significantly lower in the primary closure group [10].An alternative to T-Tube is antegrade stent placement and primary closure [13]. We did antegrade stent placement in a few cases as published earlier [4]. In one patient we had an unexpected bile leak postoperatively. This and the additional cost of an upper endoscopy for stent removal after four weeks , stopped us from doing any further stenting. A recently described option to T-Tube is placement of ureteric Catheter through cystic duct which is brought out through the abdominal wall with primary closure of CBD [14].Our successful duct clearance rate is 92% with average morbidity of 2.66% and mortality 0%. This is comparable to the data seen in the meta analysis [9].Other options such as extracorporeal shockwave lithotripsy(ESWL), Laser lithotripsy and dissolving solutions such as ursodeoxycholic acid(UDCA) and methyl- tert- butyl ether(MTBE) have not gained acceptance. They have especial indications and more clinical trials in this area are required [5].

Predictors of cbd stone

Transcholedochal Approach After opening up of the Calot’s triangle, the anterior surface of the CBD was dissected carefully and choledochotomy was performed by a longitudinal incision of 1 cm or more depending on the size of the stone with the help of endoscopic knife just below the insertion of the cystic duct into the bile duct. The stones were retrieved by spontaneous evacuation while incising the bile duct, blunt instrumental pressure with atraumatic forceps and milking, Dormia basket, Fogarty balloon catheter or irrigation and suction. Completion choledochoscopy (Fr 3.8, Olympus)was performed to assess the completeness of the procedure. Choledochotomy was closed over a t-tube with continuous 3-0 vicryl suture. Primary closure of CBD was done in cases were the ampulla was not violated and complete stone clearance was confirmed by choledochoscopy.Postoperative ERCP was done in 2 patients due to failure of transcystic approach in a non–dilated CBD. Where T-tube was placed, it was clamped on 3rd POD and patient discharged home. The tube was removed between 10th to 14th POD without a cholangiogram provided the patient had no pain abdomen,fever, nausea and vomiting and or jaundice. If the patient had any such symptom, a T-tube cholangiogram was done prior to T-tube removal. Choledochoduodenostomy was done in 2 patients as they had dilated CBD >2 cm with intrahepatic stones.A sub hepatic drain was placed in all cases which was removed on 2nd postoperative day if drain was <30 ml/ day.Patients were discharged home on the 3rd or 4th postoperative day.

IOC was performed in 342 patients (11.18%) out of 3060 laparoscopic cholecystectomies. There were114 male patients and 228 patients were female. The mean age of the patient was 41 years.Of the 342 patients 157(45.9%) were detected to have CBD stones on IOC.Out of the 158 patients, USG was suggestive of CBD calculus in 74. Stones were removed either by transcystic or by choledochotomy approach as shown in Table  3 . The mean duration of the procedure was 65 min (range 50–80 min).

Discussion

Laparoscopic CBD exploration (LCBDE) is a cost effective, efficient and minimally invasive method of treating choledocholithiasis. Laparoscopic Surgery for common bile duct stones (CBDS) was first described in 1991, Petelin (Surg Endosc 17:1705–1715, 2003). The surgical technique has evolved since then and several studies have concluded that Laparoscopic common bile duct exploration(LCBDE) procedures are superior to sequential endolaparoscopic treatment in terms of both clinical and economical outcomes, Cuschieri et al. (Surg Endosc 13:952–957, 1999), Rhodes et al. (Lancet 351:159–161, 1998). We started doing LCBDE in 1998.Our experience with LCBDE from 1998 to 2004 has been published, Gupta and Bhartia (Indian J Surg 67:94–99, 2005). Here we present our series from January 2005 to March 2009. In a retrospective study from January 2005 to March 2009, we performed 3060 laparoscopic cholecystectomies, out of which 342 patients underwent intraoperative cholangiogram and 158 patients eventually had CBD exploration. 6 patients were converted to open due to presence of multiple stones and 2 patients were converted because of difficulty in defining Calots triangle; 42 patients underwent transcystic clearance, 106 patients had choledochotomy, 20 patients had primary closure of CBD whereas in 86 patients CBD was closed over T-tube; 2 patients had incomplete stone clearance and underwent postoperative ERCP. Choledochoduodenosotomy was done in 2 patients. Patients were followed regularly at six monthly intervals with a range of six months to three years of follow-up. There were no major complications like bile leak or pancreatitis. 8 patients had port—site minor infection which settled with conservative treatment. There were no cases of retained stones or intraabdominal infection. The mean length of hospital stay was 3 days (range 2–8 days). LCBDE remains an efficient, safe, cost-effective method of treating CBDS. Primary closure of choledochotomy in select patients is a viable & safe option with shorter operative time and length of stay. LCBDE can be performed successfully with minimal morbidity & mortality.

Introduction In the era of open cholecystectomy, open common bile duct(CBD) exploration was the procedure of choice for CBD stones. However, with laparoscopic cholecystectomy (LC) becoming the gold standard for cholelithiasis, the treatment for CBD stone has changed and various options are now available. These include Endoscopic Retrograde Cholangiopancreatography(ERCP), laparoscopic CBD exploration(LCBDE) or open CBD exploration. Laparoscopic CBD exploration has all the advantages of minimal access and is also most cost effective compared to the other options [1–3]. However, advanced surgical skills are required for the performance of the procedure. Here we present our experience of LCBDE.

Management protocol for suspected CBD stones

Table 2

Transcystic Approach The catheter was removed. A guidewire was placed through the guidewire director, the director was removed and the remaining procedure was done over the guidewire. A balloon dilator was introduced to dilate the cystic duct. Then CBD stones were extracted by irrigation/suctioning, or with the help of Dormia basket/balloon catheter. A completion cholangiogram was done to confirm complete stone clearance. The cystic duct stump was closed with clips or suture ligature and the gall bladder was removed in the usual manner.

Cystic duct versus cbd approach

Pulmonary medications should be continued. Gastroesophageal reflux treatment should be enforced even for patients with rare symptoms.

A third category are patients with suspected or known pancreaticobiliary malignancy who require either curative or palliative major surgical procedures. These patients often have laparoscopic evaluation prior to the open procedure, whether done in the same setting or not as is the preference of the surgeon. They are evaluated in the preadmission clinic, have all the lab work ready, and often benefit from regional anesthesia for postoperative pain control in addition to general anesthesia. The use of invasive monitoring depends on the planned extent of the surgical procedure and the surgeon’s skills in avoiding large blood losses.

Patients may be taking nothing or they may have a long list of medications for different diseases from coronary disease, diabetes, lung disease, heartburn, chronic pain, liver disease, and neurologic and psychiatric diseases and less essential diseases such as gout, arthritis, and thyroid disease. The use of herbals and/or OTC medications with aspirin or NSAIDs should be pursued.

g. Additional systems/conditions which may be of concern in a patient undergoing this procedure and are relevant for the anesthetic plan (e.g., musculoskeletal in orthopedic procedures, hematologic in a cancer patient)

Common laboratory normal values will be same for all procedures, with a difference by age and gender.

The APACHE score can predict survival in patients admitted to the ICU, but they are not specifically evaluated for patients with cirrhosis undergoing surgery.

2. Preoperative evaluation

The most important aspects of the medical condition of nonseptic biliary tract patient are the presence and severity of liver dysfunction, along with the expected difficulty of the surgical procedure and the type of anesthetic planned. While coagulopathy is not common with biliary tract disease, its presence is a serious risk factor. Classifications of liver dysfunction have been implemented to aid clinicians with risk assessment (Table I).

Elective or semi-urgent procedures should not be performed in patients with acute or fulminant hepatitis, alcoholic hepatitis, severe chronic hepatitis, Child class C or MELD >15 cirrhosis, severe coagulopathy, or severe extrahepatic manifestations of liver dysfunction such as hypoxia, cardiomyopathy, or acute renal failure. Elective procedures are well tolerated in patients with Child’s class A or MELD <10 cirrhosis and those with mild chronic liver disease, and is tolerable in patients with Child’s class B or MELD 10-15 cirrhosis except those undergoing extensive hepatic resection or cardiac surgery.