Guidelines Management of Common Bile Duct Stones

Guidelines Management of Common Bile Duct Stones
Presented by: DR.MUHAMMAD ABUKHATER FRCS IRELAND 21/September /2011

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DR.MUHAMMAD ABUKHATER
Biliary tract stones can be found in any location
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When patients present with CBD Stone
What is the best modality of treatment ?

CBDS
Common bile duct stones (CBDSs) may occur in up to 3%14.7% of all patients for whom cholecystectomy is preformed
CBDS have symptoms

It is important to distinguish between primary and secondary stones
ERCP with or without endoscopic biliary sphincterotomy Laparoscopic CBD exploration (Transcystic or Transcholedochal) Laparotomy with CBD exploration (by Ttube insertion, or primary closure)
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Sensitivity Specificity
25% to 63% 95%
Technical success Safety Cost effectiveness It is the first line investigation in patients with suspected CBDS
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ERCP
Sensitivity 90% to 95%

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Specificity 92% to 98%

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Morbidity rate of 15.9% and a mortality rate of 1%
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The Reasons to Perform a Sphincterotomy
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Residual or recurrent common bile duct stones following cholecystectomy Biliary pancreatitis Papillary stenosis due to a tumor or scarring To facilitate the placement of a stent. Common bile duct stones in high-risk surgical patients with intact gallbladders
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MRCP
Accurate, noninvasive diagnostic modality for investigating the biliary ducts

Sensitivity of 95% and a specificity of 97%
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What are Diseases Diagnosed by MRCP ?
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(MRCP)
Biliary Disease

Cystic disease of bile duct (choledochal cyst, choledochocele, Carolis disease)
Congenital variants (low or medial duct insertion, aberrant right hepatic duct)
Choledocholilithiasis Primary sclerosing cholangitis Post-surgical biliary complications Cholangiocarcinoma, Klatskin Tumor of the Bile Duct Pancreatic Disease
Pancreas divisum
Chronic pancreatitis Pancreatic cancer
EUS
Endoscopic insertion of an ultrasound probe through the stomach and up to the second half of the duodenum Noninvasive test Highly dependent on the examiner
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Sensitivity 95%, Specificity 9598%
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EUS has a high sensitivity and specificity for detection of common bile duct stones, equal to or better than that of (ERCP), without the risks of ERCPrelated pancreatitis
Laurent Palazzo from the University of Paris

Conventional Computed Tomography (CT)
Sensitivity of 87% and a specificity of 97% for the diagnosis of CBD stones Risk of allergic reaction to contrast injection
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Intraoperative Cholangiography (IOC)

Routine use of IOC is still controversial Identify choledochal stones Open or laparoscopic cholecystectomy Sensitivity of 98% and Specificity of 94% Retained stones CBD injuries Operative time
Intervention or Surgery
Today, therapeutic decision-making is based on the local availability of expertise pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST) in atwo-stage
procedure
surgical bile duct clearance and cholecystectomy as one-stage procedure
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Kharbutli et al. reported that one-stage management of symptomatic CBDS is associated with less morbidity and mortality (7% and 0.19%) Than two-stage management (13.5% and 0.5%)
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(ERCP) Endoscopic biliary sphincterotomy (EST) Endoscopic balloon dilation of the papilla Short-term use of a biliary stent
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Laparoscopic Common Bile Duct Exploration surgical expertise adequate equipment biliary anatomy number and size of CBD stones stone clearance rates ranging from 85% to 95%, a morbidity rate of 4%16% and a mortality rate of around 0%2%
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Postoperative Evaluation and Management
Retained stones are discovered after an operation (2.5%)

laparoscopic or open exploration
Percutaneous transhepatic therapies
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1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon
Kocherization of duodenum and short longitudinal choledochotomy Stones removed with palpation, irrigation with flexible catheters, forceps, Completion with T-tube drainage For many years, this was the standard treatment for cholecystocholedocholithiasis
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Open Common Bile Duct Exploration
Choledochoenterostomy / CBD> 2 CM A- Side-to-side choledochoduodenostomy B- Choledochojejunostomy with a roux-en-Y loop Sphincterotomy
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CBD Exploration
1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon
Kocherization of duodenum and short longitudinal choledochotomy Stones removed with palpation, irrigation with flexible catheters, forceps, Completion with T-tube drainage For many years, this was the standard treatment for cholecystocholedocholithiasis
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CBD Exploration
Ideal for patient with 13 distal stones Non dilated ducts with or without T- tube insertion
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Choledochoduodenostomy
Introduced by Sprengel 1891
CBD must be > 2 cm

Low morbidity and mortality
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Choledochojejunostomy
Can be performed for CBD < 2 cm
Following previous open CBD exploration
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Transduodenal Sphincterotomy and Sphincteroplasty

Used primarily for impacted stones at the ampulla Definitive treatment of ampullary stenosis
Access to pancreatic duct
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Open Common Bile Duct Exploration

It
should not be forgot that the open approach always remains as a final option when others modalities have failed
Various Techniques for the Surgical Treatment of Common Bile Duct Stones: A Meta Review 1Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran 2Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany
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1-Which of the following is single best predicting factor for presence of CBD Stones ? A B C D
Alkaline phosphatase AST Total bilirubin Amylase
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2- CBD stones found in a patient one year after cholecystectomy are most likely A- Retained B- Recurrent C- Primary D- b and c
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3- When sphincterotomy or papillotomy are unsuccessful, the surgeon can perform which of the following for proper drainage of CBD stones
A. Choledochotomy and stone retrieval b. Transduodenal sphincteroplasty c. Choledochoduodenostomy d. Choledochojejunostomy e. All of the above
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4- When the ampulla is exposed through duodenal access, what is the preferred incision for access to the CBD
A. 5 o clock b. 3 oclock c. 11 oclock d. 2 oclock e. 12 oclock
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March 25, 2008 New guidelines issued for management of common bile duct stones (CBDS) have been published in the March 5 Online First issue of Gut.
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The British Society of Gastroenterology (BSG) commissioned these guidelines, which were subsequently reviewed, revised, and endorsed by the Clinical Standards and Services Committee of the BSG, the BSG Endoscopy Committee, the ERCP stakeholder group, the Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, and the Royal College of Radiologists
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After a preliminary search of the literature in 2004 of PubMed and MEDLINE, the findings were summarized and were presented to the British Society of Gastroenterology (BSG) Endoscopy Committee, which developed principal clinical questions to be addressed by the guidelines A multidisciplinary guideline-writing group then wrote provisional guidelines
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Some of the specific recommendations are as follows:
Hepatobiliary cases should be discussed in a multidisciplinary setting (grade C)
Symptomatic patients in whom evaluation suggests ductal stones should undergo extraction if possible (grade B)
Transabdominal ultrasound scanning (USS) is recommended as a preliminary investigation for CBDS, but it is not a sensitive test for this condition (grade B)
EUS and MR cholangiography are both highly effective at confirming CBDS; patient suitability, accessibility, and local expertise should help decide between the 2 procedures (grade B)
When performing endoscopic stone extraction (ESE), the endoscopist should be assisted by a technician or radiologist who can help with fluoroscopy, a nurse for safety monitoring, and an additional endoscopy assistant or nurse to manage guide wires and other technical aspects as needed (grade C)
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ERCP should be done only in patients who are expected to require an intervention; it is not recommended for use solely as a diagnostic test (grade B)
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Full blood count and prothrombin time/international normalized ratio (PT/INR) should be performed within 72 hours before biliary sphincterotomy for ductal stones; patients with abnormal clotting should undergo subsequent management based on locally agreed guidelines (grade B)
For patients treated with anticoagulants but who are at low risk for thromboembolism, anticoagulants should be discontinued before endoscopic stone extraction if biliary sphincterotomy is planned (grade B) as should newer antiplatelet agents (eg, clopidogrel), 7 to 10 days before biliary sphincterotomy (grade C). Use of aspirin, nonsteroidal antiinflammatory drugs (NSAIDs), and low-dose heparin should not be considered a contraindication to biliary sphincterotomy (grade B)
Patients with biliary obstruction or previous features of biliary sepsis should receive prophylactic antibiotics (grade A)
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Sphincterotomy initiated with use of pure cut may be preferred in patients with risk factors for post-ERCP pancreatitis but not biliary sphincterotomyinduced hemorrhage (grade A)
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In most patients undergoing stone extraction, balloon dilation of the papilla should be avoided because the risk for severe post-ERCP pancreatitis is increased vs biliary sphincterotomy (grade A)
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Short-term use of a biliary stent, followed by further endoscopy or surgery, is recommended to ensure adequate biliary drainage in patients with CBDS that have not been extracted (grade B)
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Use of a biliary stent as sole treatment of CBDS should be limited to patients with limited life expectancy or prohibitive surgical risk, or both (grade A)
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Pre-cut is a risk factor for complication and should be used only by those with appropriate training and experience and only in patients for whom subsequent endoscopic treatment is essential (grade B)
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Operative risk should be evaluated before scheduling intervention, and endoscopic therapy should be considered as an alternative in highrisk patients (grade B)
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Intraoperative cholangiography or laparoscopic ultrasound can detect CBDS in patients who are suitable for surgical exploration or postoperative ERCP (grade B)
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In patients undergoing laparoscopic cholecystectomy, transcystic and transductal exploration of the common bile duct are both considered appropriate for removal of CBDS (grade A)
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When minimally invasive techniques fail to achieve duct clearance, open surgical exploration is still considered to be an important treatment option (grade B)
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The guidelines also discuss supplementary treatments including - Mechanical lithotripsy - Extracorporeal shock wave lithotripsy - Electrohydraulic lithotripsy - Laser lithotripsy - Percutaneous treatment - Oral ursodeoxycholic acid - Management of specific clinical scenarios is also presented
"Biliary sphincterotomy and endoscopic stone extraction (ESE) is recommended as the primary form of treatment for patients with CBDS post cholecystectomy"
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The authors of the guidelines write. "Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones, unless there are specific reasons for considering surgery inappropriate
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Patients with CBDS undergoing laparoscopic cholecystectomy may be managed by laparoscopic common bile duct exploration (LCBDE) at the time of surgery, or undergo peri-operative ERCP
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Based on the BSG guidelines, which of the following statements about evaluation of CBDS is correct?
Transabdominal USS is a sensitive test for CBDS EUS is significantly less effective than MR cholangiography for confirming CBDS EUS is significantly more effective than MR cholangiography for confirming CBDS Transabdominal USS is recommended as a preliminary investigation for CBDS
Based on the BSG guidelines, which of the following statements about treatment of CBDS is not correct?
Perioperative ERCP is not recommended for patients with CBDS undergoing laparoscopic cholecystectomy Biliary sphincterotomy and endoscopic stone extraction (ESE) are recommended as the primary forms of treatment of patients with CBDS postcholecystectomy Cholecystectomy is recommended for all patients with CBDS and symptomatic gallbladder stones, unless they are not surgical candidates Patients with CBDS undergoing laparoscopic cholecystectomy may be treated by laparoscopic common bile duct exploration (LCBDE) at the time of surgery
THANK YOU
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Guidelines Management of Common Bile Duct Stones

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Guidelines Management of Common Bile Duct Stones

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Guidelines Management of Common Bile Duct Stones

Presented by: DR.MUHAMMAD ABUKHATER FRCS IRELAND 21/September /2011

Biliary tract stones can be found in any location

When patients present with CBD Stone

What is the best modality of treatment ?

CBDS have symptoms

25% to 63% 95%

5/4/2012 DR.MUHAMMAD ABUKHATER 7

Sensitivity 90% to 95%

Specificity 92% to 98%

Morbidity rate of 15.9% and a mortality rate of 1%

The Reasons to Perform a Sphincterotomy

Accurate, noninvasive diagnostic modality for investigating the biliary ducts

What are Diseases Diagnosed by MRCP ?

Cystic disease of bile duct (choledochal cyst, choledochocele, Carolis disease)

Sensitivity 95%, Specificity 9598%

Laurent Palazzo from the University of Paris

Conventional Computed Tomography (CT)

Intraoperative Cholangiography (IOC)

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surgical bile duct clearance and cholecystectomy as one-stage procedure

5/4/2012 DR.MUHAMMAD ABUKHATER 28

Postoperative Evaluation and Management

Retained stones are discovered after an operation (2.5%)

Percutaneous transhepatic therapies

1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon

Open Common Bile Duct Exploration

Choledochoenterostomy / CBD> 2 CM A- Side-to-side choledochoduodenostomy B- Choledochojejunostomy with a roux-en-Y loop Sphincterotomy

1889, 1st CBD exploration by Ludwig Courvoisier, a Swiss surgeon

CBD must be > 2 cm

Following previous open CBD exploration

Transduodenal Sphincterotomy and Sphincteroplasty

Open Common Bile Duct Exploration

Alkaline phosphatase AST Total bilirubin Amylase

A. 5 o clock b. 3 oclock c. 11 oclock d. 2 oclock e. 12 oclock

Some of the specific recommendations are as follows:

Hepatobiliary cases should be discussed in a multidisciplinary setting (grade C)

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