SURGICAL AND INSTRUMENTAL

MANAGEMENT OF RETAIN CBD

STONE

Dr. M. Iqbal Rivai Sp.B KBD

Digestive Division, Dr.M.Djamil Hospital, West Sumatra
THE PROBLEM
• 15-20% of cholelithiasis with CBD stone
• After biliary tract surgery, 2-10% with residual stone
• 5-12% residual stone asymtomatic
• Dx post-op T-tube cholangiogram distressed both the
patient and the surgeon
• CBD re-exploration; mortality 3-28% and morbidity 20-30%
 RISK FACTOR FOR
RETAIN STONES
• Dilated CBD
• Gall bladder stone
• Biliary stricture
• Angulation of CBD
• Previous open cholecystectomy
• Periampullary diverticulum
 MANAGEMENT OF RETAIN STONE

Depends on :
• Expertise and facilities available
• Age and general health of the patient
• Size of stone
• Whether a T tube is in place
• Previous procedure
GENERAL CONSIDERATION
• If the GB has been removed previously, an endoscopic
extraction of CBD stones is the preferred approach
• Extraction via T tube tract is safe and cost effective
• ERCP/spincterotomy is a valuable method
• Endo and laparoscopy : learning curve, longer
operative time, lack equipment
• Recurrent stone after prior open exploration/
biliodigestive anastomose  re-exploration
Stricture, adhesi : factors that limit endoscopic
procedure
T TUBE IN SITU, WHAT WE CAN DO ?
• Saline or heparinized saline flushed
For small stone and given glucagon (succes rate 50%)
Motson, Br.J.Surg
• Perform after 12th day postoperative day
• Infuse 1000 ml saline with 5000 unit heparin via T tube
24 h
• Contraindicated if stone completely blocks CBD
• Repeat every 4-5 day
 T-TUBE IN SITU, WHAT WE CAN DO ?
• Percutaneous extraction
• Stone extraction via the T tube tract after 4-6 weeks
14F or larger T tube (Burhenne report : succes rate
95% in 661 patients)
• Insert flexible catheter by Medi-Tech
• Dormia stone basket
DISSOLUTION
• Ursodeoxycholic acid and Methyl-Tert-butyl-Ether
• Cholesterol solvent
• Into CBD for retain stone through T tube (14F or larger)
• MTBE toxic to the liver and duodenal mucosa
• For small-medium stone
 ENDOSCOPIC MANAGEMENT
• Endoscopic sphincterotomy
• Mechanical lithotripsy
• Intraductal shockwave lithotripsy
- Electrodydraulic
- Laser
• ESWL
• Dissolution
- Ursodeoxycolic acid
- Methyl tert-buthyl ether (MBTE)
• Long term stent
• The choice of technique depends on local and the
previous procedure
 ENDOSCOPIC SPHINCTEROTOMY (ES) &
ENDOSCOPIC PAPILLARY BALLON DILATATION (EPBD)

• Multi-center RCT : low clearance & high morbidity, when

compared with open surgery
• Schmitt reported ES succes rate 100% removal stone
Schmitt CM, et al. HPB Surgery (1995)

• EPBD wtih dormia basket

Large stone >20 mm require stone fragmentation
• ES vs EPBD
 ENDOSCOPIC SPHINCTEROTOMY (ES)

Reason for failure :

• Large size of the stone
• Technical difficulty in cannulation
• Pariampullary diverticulum
• Impacted stone

Ballon cath + wire basket following sphincterotomy

give good result
LAPAROSCOPIC EXP CBD
MECHANICAL LITHOTRIPSY
• Bile duct clearance 80-90%
• For large stone >20 mm
• Advantages
- Easy to use
- Low cost
- For larger and impacted stone
• Disadvantages
- Require stone capture
- > 1 procedure

GASTROINTESTINAL ENDOSCOPY, 65:6 2007

 ES-LBD VS ML
• ES-LBD is equally effective as ES-ML for large stone (>12
mm)
• ES-ML the procedure of choice for stone >20mm
• Post-operative complication significantly less in ES-LBD
compared with ES-ML (4% vs 20%)
• Cholangitis more common in ES-ML

Stefanidis et al. 2011

ELECTROHYDROLIC LITHOTRIPSY (EHL)

• Via peroral to fragment large bile duct

• Best achieved under direct choledochoscopic and fluoroscopic
visualization
• EHL probe is commonly used in the SpyGlass system
LASER LITHOTRIPSY
• For complicated biliary stones using direct choledochoscopy
• The second-line modality after ERCP
• Require multiple sessions
 OPEN DRAINAGE PROCEDURE
When
Why • Recurrent CBD stone
• Fail to fragment stone • Impacted large CBD
• Fail endoscopic and T stone
tube stone extraction • Dilated CBD
• Familiar with the local • Multiple CBD stone
surgeon
How
• Facilities
• Transduodenal
sphincteroplasty
• Choledochoduodenostomy
• Choledochojejunostomy
CONCLUSION
• Retain billiary distressed both the patient and the surgeon
• The choice of technique depends on Expertise and facilities
available
• Endoscopic techniques are effective for the treatment of
retained CBD stones
• Very large stones/complicated can be very challenging to
manage
• Another techniques, such as mechanical lithotripsy, EHL,
laser, ESWL and Open drainage procedure