management of choledocholithiasis - department of · pdf filemanagement of choledocholithiasis...

Management of Management of ggCholedocholithiasisCholedocholithiasis

SUNY Downstate Medical CenterKings County Hospital

Department of Surgery Grand RoundsDepartment of Surgery Grand RoundsKiyanda Baldwin

October 22, 2009

www.downstatesurgery.org

Case PresentationCase PresentationCase PresentationCase Presentation43 y/o F c/o jaundice x 3 days associated with y j ynausea & anorexia

PMH: HTN CVAPMH: HTN, CVA

PSH: c-section x2

Meds: norvasc

All: nkda

SH t b 1 d 20 it 10 d i SH: tobacco 1ppd x 20yrs quit 10 yrs ago, denies illicit drug or etoh use


Physical ExamPhysical ExamPhysical ExamPhysical ExamAfebrile, hemodynamically normal

Scleral icterusScleral icterus

Abd soft obese NT +BS no Abd soft, obese, NT, +BS no rebound/guarding, no masses appreciated

Otherwise wnl


LabsLabsLabsLabs

Wbc 6.3

Ast/Alt 237/335, AP/Tb 451/12.9

Am/Lip 340/880


RadiologyRadiologyRadiologyRadiologyU/S cholelithiasis, CBD 9mm

MRCP: gallstones, CBD 2.4cm,Multiple CBD p

defects up to1 3cm1.3cm

ERCP hi 10F 11 ERCP, sphincterotomy, 10Fr. 11cm stent placement, unable to extract stones


Hospital CourseHospital CourseHospital CourseHospital CourseHD 2 amylase & lipase decrease by halfHD 2 amylase & lipase decrease by half

Pt optimized for OR

HD 10: ex-lap, cholecystectomy, CBD exploration with stone extraction, p ,choledochoduodenostomy


ExEx--Lap Lap CholecystectomyCholecystectomyExEx Lap, Lap, CholecystectomyCholecystectomyR subcostal incisionR. subcostal incision

Contracted intrahepaticgallbladder resected in retrograde fashion

Cystic duct almost obliterated, GB y ,transected at its base, CBD ~4cm


CBD ExplorationCBD ExplorationCBD ExplorationCBD ExplorationKocher maneuver duodenal mobilizationKocher maneuver, duodenal mobilization

1.5cm longitudinal incision made in CBD1.5cm longitudinal incision made in CBD

CBD stent removed

Large distal stone extracted w/ atraumaticforcepsforceps

Smaller common hepatic and bile duct stones Smaller common hepatic and bile duct stones extracted with fogarty catheter


CholedochoduodenostomyCholedochoduodenostomyCholedochoduodenostomyCholedochoduodenostomyLongitudinal incision made in 3rd portion of duodenum

Diamond-shaped single layer side to side anastomosis w/ 4-0 vicryly

No 10 JP left near anastomosisNo. 10 JP left near anastomosis

Pt extubated in OR and tolerated procedure well


Postoperative CoursePostoperative CoursePostoperative CoursePostoperative CoursePOD 2: clear liquidsPOD 2: clear liquids

POD 3: full bowel function started on regdiet

POD 4: discharged homeg

POD 11: outpt doing wellPOD 11: outpt, doing well


?QUESTIONS??QUESTIONS?


Management Management f of

h l d h l hCholedocholethiasis


GoalsGoalsGoalsGoalsT l i di i f h l d h li hi iTools in diagnosis of choledocholithiasis

T t tTreatment◦ ERCP

Ch l d d l◦ Cholangiogram and duct exploration◦ Choledochal drainage procedures

Duct exploration vs postop ERCP

Biliary stents?


EtiologyEtiologygygyBilirubin, bile salts, phospholipids, cholesterol

Secondary stones◦ 75% cholesterol: cholesterol saturation, biliary stasis◦ 25% black stones (calcium bilirubinate): hemolytic

disorders, cirrhosis, prolonged fasting, TPN

Primary stones◦ Brown pigment: lower in cholesterol higher in Brown pigment: lower in cholesterol, higher in

bilirubin, soft & easy to crumble◦ Biliary stasis & bacteriay◦ Increased in SE asian populations

Current Surgical Therapy 9th Edition Cameron 2008


CholedocholethiasisCholedocholethiasisCholedocholethiasisCholedocholethiasis6 12% of pts w/ GB stones6-12% of pts w/ GB stones

20 25% of pts >60 y/o w/ symptomatic 20-25% of pts >60 y/o w/ symptomatic GB stones

Secondary stones-cholesterol, primary-brown pigmentbrown pigment

Primary-associated w/ stricture, stenosis, Primary associated w/ stricture, stenosis, tumors, secondary stones

Schwartz’s Principles of Surgery, 8th Edition 2005


ManifestationsManifestationsManifestationsManifestationsBiliary colicBiliary colic

Gallstone pancreatitis

Ascending cholangitis

Elevated bilirubin, alk phos, transaminases; 1/3 normal LFTs1/3 normal LFTs



RadiologyRadiologyRadiologyRadiologyU/S

Magnetic resonance cholangiography◦ Sens/spec 95 & 89% for >5mm

Endoscopic cholangiography – gold standard◦ Successful >90%, morbidity <5% (cholangitis,

pancreatitis), mortalitiy 0.2%

Endoscopic u/sSchwartz’s Principles of Surgery, 8th Edition 2005


TreatmentTreatmentTreatmentTreatmentERCP w/ sphincterotomy & duct p yclearance followed by lap chole

Lap chole w/ postop ERCP & sphincterotomy (failure rate 4-10%)sphincterotomy (failure rate 4-10%)

Ch l t t / i tCholecystectomy w/ intraopcholangiogram



ACS Surgery: Principles & Practice 2009


ERCPERCP1968 first ERCP

Side viewing endoscope

CBD cannulated & cholangiogram under fluoro, >90% successful

1973 first sphincterotomy

Sphincteromy, balloon sphincteroplasty (6-8 22% f il ) b k 8mm, 22% failure rate), basket sweep



ERCPERCPERCPERCPwww.downstatesurgery.org

Intraoperative CholangiogramIntraoperative Cholangiogramp g gp g g



IntraopIntraop ManagemntManagemnt of CBD Stonesof CBD StonesIntraopIntraop ManagemntManagemnt of CBD Stonesof CBD StonesFlush small stones after relaxing sphincter of Oddiw/ 1-2mg glucagonw/ 1-2mg glucagonTranscystic duct exploration w/ fluoroscopic balloon catheterization and wire basket sweepcatheterization and wire basket sweep◦ Indications: cbd 6mm, stones are distal to cystic-

CBD junction, cystic duct >4mm, <6-8 CBD j , y ,stones

If stones 4-8mm, use choledochoscope (endoscopic p ( ptranscystic CBD exploration)If stone >1cm lap CBD exploration w/ choledochotomy & 10-14Fr T-tube



TranscysticTranscystic Duct ExplorationDuct ExplorationTranscysticTranscystic Duct ExplorationDuct Exploration



Open CBD explorationOpen CBD explorationIndications: failed ERCP, failed laparoscopic attempts, surgeon’s comfortKocher maneuver1-2cm incision in CBD ant wall w/ 2 stay suturesRespect arterial supply at 3 & 9 o’clockUse forceps, fogarty cath, wire baskets



TT--tube managementtube managementRpt cholangiogram through T-tubeNo stones clamp tube & remove in 2 wksNo stones clamp tube & remove in 2 wksRetained stones stone retrieval after 4-6 wks



Success & M/M RatesSuccess & M/M RatesSuccess & M/M RatesSuccess & M/M RatesTranscystic CBD explorationy p◦ Success 71-98%◦ Morbidity 0-14% (cystic duct leak, bile duct y ( y ,

perf, pancreatitis), retained stones 2-5%

Lap CBD exploration w/ cholodochotomy◦ Success 85-97%Success 85 97%◦ Morbidity 3-16%



CholedochalCholedochal Drainage Drainage ggProceduresProcedures

Transduodenal sphincterotomyp y

CholedochoduodenostomyCholedochoduodenostomy

Ch l d h j jCholedochojejunostomy


Indications for Indications for CholedochalCholedochalDrainage ProceduresDrainage Procedures

I bl i d di l CBD Irremovable, impacted, distal CBD stones

Markedly dilated CBD >1 5cmMarkedly dilated CBD, >1.5cm

Distal duct obstruction from tumor or Distal duct obstruction from tumor or stricture

Recurrence after previous duct explorationp

Schwartz’s Principles of Surgery, 8th Edition 2005Maingot’s Adominal Operations 11th Edition 2007


TransduodenalTransduodenal SphincterotomySphincterotomy

Useful for stone impaction in ampulla of Vater, papillary stenosis multiple stenosis particularly in papillary stenosis, multiple stenosis particularly in nondilated duct

Kocher maneuver

Cannulate ampulla by passing Fogarty into CBD

Longitudinal duodenotomy over ampulla

Locate pancreatic duct at 4 o’clockMaingot’s Adominal Operations 11th Edition 2007


TransduodenalTransduodenal SphincterotomySphincterotomyTransduodenalTransduodenal SphincterotomySphincterotomy

Sphincterotomy at 11 o’clock w/ sequential Sphincterotomy at 11 o clock, w/ sequential sutures

Biliary dilator the size of the CBD

Close duodenotomy in transverse direction

Leave a drain

Maingot’s Adominal Operations 11th Edition 2007


TransduodenalTransduodenal SphincterotomySphincterotomyp yp ywww.downstatesurgery.org

CholedochoduodenostomyCholedochoduodenostomyCholedochoduodenostomyCholedochoduodenostomyIndicationsIndications◦ Recurrent stones

◦ Impacted or giant stones

Bili l d◦ Biliary sludge

◦ Ampullary stenosis◦ Ampullary stenosis

◦ Funnel syndromey



CholedochoduodenostomyCholedochoduodenostomyCBD at least 1.2cm

CholedochoduodenostomyCholedochoduodenostomy

Kocherize duodenum1-2cm distal choledochotomy1-2cm distal choledochotomyClear CBD stonesL i di l d dLongitudinal duodenotomySide to side single-layered anastomosis w/ absorbable suturePlace drain



CholedochoduodenostomyCholedochoduodenostomywww.downstatesurgery.org

CholedochoduodenostomyCholedochoduodenostomyMorbidity/mortality: 23 & 3%Morbidities: Morbidities: ◦ Cholangitis 0-6%◦ Sump syndromeSump syndrome◦ Wound infection, anastomotic leak,

intraabdominal abscessintraabdominal abscess(most important factor: large distal stoma)

Mortalities: usually medicalMortalities: usually medical◦ PE, MI, heart failure

70 80% as m t matic after 5 rs70-80% asymptomatic after 5 yrsMaingot de Aretxabala X, Bahamondes JC. Choledochoduodenostomy for common bile duct stones. World J Surg 1998;22:1171–1174 , Maingot’s Adominal Operations 11th Edition 2007


CholedochojejunostomyCholedochojejunostomyRetrocolic 45-60cm roux-en-y w/ end to

CholedochojejunostomyCholedochojejunostomy

side anastomosis

I d b b bl Interrupted absorbable Sutures

Protects against intestinal fl & d h l i ireflux & secondary cholangitis

Leave a drain ☺Leave a drain ☺


RandomisedRandomised trial of laparoscopic exploration of common trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde bile duct versus postoperative endoscopic retrograde cholangiographycholangiography for common bile duct stonesfor common bile duct stonesM Rhodes, L M Rhodes, L SussmanSussman, L Cohen, M P Lewis, L Cohen, M P LewisM Rhodes, L M Rhodes, L SussmanSussman, L Cohen, M P Lewis, L Cohen, M P Lewis

1995-19971995 1997Norfolk and Norwich Trust Hospital, UKIntention to treat analysisIntention to treat analysisPrimary end points: duct clearance,

bidi OR i h i l morbidity, OR time, hospital stay

THE LANCET • Vol 351 • January 17, 1998


LECBD LECBD vsvs PostopPostop ERCPERCPLECBD LECBD vsvs PostopPostop ERCPERCP

LECBDLECBD◦ 7 pts w/ morbidities◦ 1 open 2 readmissions pain control 3 bile ◦ 1 open, 2 readmissions – pain control, 3 bile

leaks from stents, 1 urinary retention

ERCP◦ 6 pts w/ morbidities◦ 6 pts w/ morbidities◦ 1 postop hemorrhage, 1 bile leak, 3 post

sphincterotomy bleeding 1 retained stonesphincterotomy bleeding, 1 retained stone


LECBD LECBD vsvs PostopPostop ERCPERCPLECBD LECBD vsvs PostopPostop ERCPERCPwww.downstatesurgery.org

BiliaryBiliary StentsStentsBiliaryBiliary StentsStentsDiFronzo et al, Kaiser Permanente, ’98◦ 97 pts w/ biliary-enteric anastomosis w/o

stent◦ 1 case, 1% anastomotic leak

Innes et al, Ohio State, ’88, ,◦ 22 pts w/ reconstructive biliary-enteric

anastomosis due to stricture w/o stent◦ 4 complications: 1 fistula, 1 abscess, 2

reccurrent stricture


SummarySummaryyyTo detect CBD stones◦ U/S MRCP ERCP Cholangiogram◦ U/S, MRCP, ERCP, Cholangiogram

To remove stonesERCP i d l i CBD ◦ ERCP, transcystic duct exploration, CBD exploration (irrigate, balloon, basket)

Bili D i P dBiliary Drainage Procedures◦ Transduodenal sphincterotomy,

h l d h d d t choledochoduodenostomy, choledochojejunostomy

There is a role for operative CBD explorationsThere is a role for operative CBD explorationsBiliary Stents?


ReferencesReferencesReferencesReferences1. Schwartz’s Principles of Surgery, 8th Edition 2005

2 Current Surgical Therapy 9th Edition Cameron 20082. Current Surgical Therapy 9th Edition Cameron 2008

3. ACS Surgery: Principles & Practice 2009

4. Maingot’s Adominal Operations 11th Edition 2007

5 Zollinger’s Atlas of Surgical Operations 8th Edition 20035. Zollinger s Atlas of Surgical Operations 8 Edition 2003

6. Fitzgibbons RJ, Gardner GC: Laparoscopic surgery and the common bile duct. World J Surg 2001; 25:1317.

7. Hungness ES, Soper NJ: Management of common bile duct stones. J GastrointestSurg 2006; 10:612.

8. Rhodes M, Sussman L: Randomized trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones. Lancet 1998; 351:159. duct stones. Lancet 1998; 351:159.

9. DiFronzo LA, Egrari S, O'Connell TX. Safety and durability of single-layer, stentless, biliary-enteric anastomosis. Am Surg 1998;64:917–920

10. Tocchi A, Costa G, Lepre L, et al. The long-term outcome of hepaticojejunostomy in the treatment of benign bile duct strictures. Ann Surg 1996;224:162–167


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