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cbd stone management ppt

11 1 stage procedure Two methods for LECBD 2) Choledochotomy
1) Transcystic duct exploration Preferred method for small CBD stones and small calibre CBD 2) Choledochotomy Multiple (>3), Large CBD stone (>1 cm ) Failed transcystic duct treatment CBD > or = 9 mm on cholangiogram

32 UCH experience 2005-2006 Hospital stay Morbidity Mortality
Mean= 12.8 days (9-17) Morbidity 1 case of retained stone 1/25 (4%) 1 case with distal CBD stricture 1/25 (4%) 1 case with retained transcystic duct drain require laparotomy and ERCP 1/25 (4%) Mortality 0%

Presentation on theme: “The management of patients with CBD stone and gallstone”— Presentation transcript:

7 2 stage procedure (ERCP + lap cholecystectomy)

9 2 stage procedure Advantage Avoid the need of T-tube
Avoid the need of choledochotomy Avoid the complications of ECBD Need not to have expertise/operation set-up on LECBD

15 Pre-op diagnosis & management
Diagnosis: Clinical history and exam, LFTs, Abdominal U/S, CT, MRCP High risk (>50%) of choledocholithiasis: clinical jaundice, cholangitis, CBD dilation or choledocholithiasis on ultrasound Tbili > 3 mg/dL correlates to 50-70% of CBD stone Moderate risk (10-50%): h/o pancreatitis, jaundice correlates to CBD stone in 15% elevated preop bili and AP, multiple small gallstones on U/S Low risk (<5%): large gallstones on U/S no h/o jaundice or pancreatitis, normal LFTs Treatment: ERCP Surgery

13 Our case… Condition: ERCP attempted
No acute distress, reasonably soft abdomen ERCP attempted Duct unable to cannulate due to presence of duodenum diverticulum at site of ampulla of Vater Laparoscopic cholecystectomy planned Dissection of triangle of Calot Cystic duct and artery visualized and dissected Cystic duct ductotomy Insertion of cholangiogram catheter advanced and contrast bolused into cystic duct for IOC Intraoperative cholangiogram Several common duct filling defects consistent with stones Decision to proceed with CBD exploration

8 Diagnosis: lab values CBC Metabolic panel Amylase/Lipase
79% of patients have WBC > 10,000, with mean of 13,600 Septic patients may be neutropenic Metabolic panel Low calcium if pancreatitis 88-100% have hyperbilirubinemia 78% have increased alkaline phosphatase AST and ALT are mildly elevated Aminotransferase can reach 1000U/L- microabscess formation in the liver GGT most sensitive marker of choledocholithiasis Amylase/Lipase Involvement of lower CBD may cause 3-4x elevated amylase Blood cultures 20-30% of blood cultures are positive

Presentation on theme: “Cholangitis & Management of Choledocholithiasis”— Presentation transcript:

16 Intra-op diagnosis and management
Diagnosis: intraoperative cholangiography (IOC) Cannulation of cystic duct, filling of L and R hepatic ducts, CBD and common hepatic duct diameter, presence or absence of filling defects. Detect CBD stones Potentially identify bile duct abnormalities, including iatrogenic injuries Sensitivity 98%, specificity 94% Morbidity and mortality low Treatment Open CBD exploration Most surgeons prefer less invasive techniques Laparoscopic CBD exploration via choledochotomy: CBD dilatation > 6mm via cystic duct ( %) CBD clearance rate 97% Morbidity rate 9.5% Stones impacted at Sphincter of Oddi most difficult to extract Intraoperative ERCP

7 Clinical Manifestations
RUQ pain (65%) Fever (90%) May be absent in elderly patients Jaundice (60%) Hypotension (30%) Altered mental status (10%) Charcot’s Triad: Found in 50-70% of patients Reynold’s Pentad: Additional History Pruitus, acholic stools PMH for gallstones, CBD stones, Recent ERCP, cholangiogram Additional Physical Tachycardia Mild hepatomegaly

4 Introduction Cholangitis is bacterial infection superimposed on biliary obstruction First described by Jean-Martin Charcot in 1850s as a serious and life-threatening illness Causes Choledocholithiasis Obstructive tumors Pancreatic cancer Cholangiocarcinoma Ampullary cancer Porta hepatis Others Strictures/stenosis ERCP Sclerosing cholangitis AIDS Ascaris lumbricoides

6 Pathogenesis Normally, bile is sterile due to constant flush, bacteriostatic bile salts, secretory IgA, and biliary mucous; Sphincter of Oddi forms effective barrier to duodenal reflux and ascending infection ERCP or biliary stent insertion can disrupt the Sphincter of Oddi barrier mechanism, causing pathogeneic bacteria to enter the sterile biliary system. Obstruction from stone or tumor increases intrabiliary pressure High pressure diminishes host antibacterial defense- IgA production, bile flow- causing immune dysfunction, increasing small bowel bacterial colonization. Bacteria gain access to biliary tree by retrograde ascent Biliary obstruction (stone or stricture) causes bactibilia E Coli (25-50%) Klebsiella (15-20%), Enterobacter (5-10%) High pressure pushes infection into biliary canaliculi, hepatic vein, and perihepatic lymphatics, favoring migration into systemic circulation- bacteremia (20-40%). Adam.about.com Gpnotebook.co.uk Pathology.med.edu

10 Diagnostic: MRCP and ERCP
Magnetic resonance cholangiopancreatography (MRCP) Advantage Detects choledocholithiasis, neoplasms, strictures, biliary dilations Sensitivity of %, specificity of % of choledocholithiasis Minimally invasive- avoid invasive procedure in 50% of patients Disadvantage: cannot sample bile, test cytology, remove stone Contraindications: pacemaker, implants, prosthetic valves Indications If cholangitis not severe, and risk of ERCP high, MRCP useful If Charcot’s triad present, therapeutic ERCP with drainage should not be delayed. Endoscopic retrograde cholangiopancreatography (ERCP) Gold standard for diagnosis of CBD stones, pancreatitis, tumors, sphincter of Oddi dysfunction Therapeutic option when CBD stone identified Stone retrieval and sphincterotomy Disadvantage Complications: pancreatitis, cholangitis, perforation of duodenum or bile duct, bleeding Diagnostic ERCP complication rate 1.38% , mortality rate 0.21%

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Common Bile duct stones (CBD) continue to pose a significant problem both to the patient and the Surgeon. They increase the morbidity of a patient undergoing Cholecystectomy from less than 5% to as much as 20% and almost zero mortality to as high as 30%. Recent times have thrown up a fair share of controversy in the management of this condition both due to technological innovations and costreduction-pressures. The aim in CBD stone disease, as in any benign disease is to discover a therapeutic algorithm with minimal morbidity, no mortality and at reasonable cost. This can be achieved only by a thorough understanding of the disease and also the available diagnostic and treatment modalities.This article dicusses the diagnosis, investigation and therapy of Common Bile Duct Stones (CBD) and gives a therapeutic algorithm.

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