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Management of Management of ggCholedocholithiasisCholedocholithiasis
SUNY Downstate Medical CenterKings County Hospital
Department of Surgery Grand RoundsDepartment of Surgery Grand RoundsKiyanda Baldwin
October 22, 2009
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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
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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
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LabsLabsLabsLabs
Wbc 6.3
Ast/Alt 237/335, AP/Tb 451/12.9
Am/Lip 340/880
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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
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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
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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
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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
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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
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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
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?QUESTIONS??QUESTIONS?
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Management Management f of
h l d h l hCholedocholethiasis
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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?
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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
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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
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ManifestationsManifestationsManifestationsManifestationsBiliary colicBiliary colic
Gallstone pancreatitis
Ascending cholangitis
Elevated bilirubin, alk phos, transaminases; 1/3 normal LFTs1/3 normal LFTs
Schwartz’s Principles of Surgery, 8th Edition 2005
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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
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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
Current Surgical Therapy 9th Edition Cameron 2008
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ACS Surgery: Principles & Practice 2009
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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
Current Surgical Therapy 9th Edition Cameron 2008
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ERCPERCPERCPERCPwww.downstatesurgery.org
Intraoperative CholangiogramIntraoperative Cholangiogramp g gp g g
Schwartz’s Principles of Surgery, 8th Edition 2005
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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
ACS Surgery: Principles & Practice 2009
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TranscysticTranscystic Duct ExplorationDuct ExplorationTranscysticTranscystic Duct ExplorationDuct Exploration
ACS Surgery: Principles & Practice 2009
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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
ACS Surgery: Principles & Practice 2009
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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
ACS Surgery: Principles & Practice 2009
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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%
Current Surgical Therapy 9th Edition Cameron 2008
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CholedochalCholedochal Drainage Drainage ggProceduresProcedures
Transduodenal sphincterotomyp y
CholedochoduodenostomyCholedochoduodenostomy
Ch l d h j jCholedochojejunostomy
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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
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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
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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
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TransduodenalTransduodenal SphincterotomySphincterotomyp yp ywww.downstatesurgery.org
CholedochoduodenostomyCholedochoduodenostomyCholedochoduodenostomyCholedochoduodenostomyIndicationsIndications◦ Recurrent stones
◦ Impacted or giant stones
Bili l d◦ Biliary sludge
◦ Ampullary stenosis◦ Ampullary stenosis
◦ Funnel syndromey
Maingot’s Adominal Operations 11th Edition 2007
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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
Maingot’s Adominal Operations 11th Edition 2007
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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
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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 ☺
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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
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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
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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
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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?
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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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