surgical management of choledocholithiasis management... · 2016-11-10 · quesons which of the...
TRANSCRIPT
SurgicalManagementofCholedocholithiasis
UniversityHospitalofBrooklynL.YukoShimotake,MDNovember10,2016
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CasePresentaHon
• 81yomalepresentedtoambulatorysurgeryforroboHccholecystectomy.
• PMHx:Hypertension,CVA,CAD• PSHx:Denies• Allergies:NKDA• SocialHx:Historyofalcoholism(quitin6monthsago),deniescigareResorillicitdruguse
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CasePresentaHon
• Previousadmission–3monthsprior– Choledocholithiasis– GallstonepancreaHHs– AscendingcholangiHs
12.9837.9
13344 1359717
3.6281.08127
6.454439
2.85749.8
Amylase295Lipase769
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CasePresentaHon• CTA/P– CholelithiasisandcholedocholithiasiscausingobstrucHon
– Secondaryintra-andextra-hepaHcductaldilataHon– PancreaHcductaldilataHon– CBD1.4cm
• IntervenHon– IVanHbioHcs– ERCP
• removalof2largegallstones• stentplacement
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CasePresentaHon
• OperaHon– RoboHcconvertedtoopencholecystectomy– CommonbileductexploraHon– Omentalpatchofduodenotomy
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CasePresentaHon
• Intra-operaHvefindings:– Denseadhesionsinvolvingtransversecolonandduodenum
– Contractedgallbladder
– Choleduodenalfistula– ImpactedstoneswithintheCBD
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CommonBileDuctExploraHon• ExposeanteriorCBD• Lateralstaysutures• VerHcalincisionoftheCBD• IrrigaHonwithcatheter• Ballooncatheterfogerty• Basket• Stoneforceps• Choledochoscope• T-tubeplacement• Closecholedochotomy
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CasePresentaHon
• Post-operaHvecourse– UrinaryretenHon– Delirium– BileductevaluaHon– DischargedhomePOD#11
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QuesHons?www.downstatesurgery.org
SurgicalManagementofCholedocholithiasis
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Outline
• Gallstones• Gallstonesyndromes• Choledocholithiasis• Sequelaeofcholedocholithiasis• DiagnosHcimaging• TreatmentopHons• Refractorystones
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Gallstones
• Cholesterolstones– >70%cholesterol+calcium+bilepigments
• Blackstones– Small,briRlestones– HemolyHcdisorders
• Brownstones– BacterialinfecHons–EColibeta-glucuronidase
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Gallstones
• Riskfactors– Female– FerHle– Obesity– Diet– Diseasestates
• s/pterminalileumresecHon• s/pgastricresecHon• Crohn’sdisease• Pregnancy
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GallstoneSyndromes
• AsymptomaHccholelithiasis
• Biliarycolic• AcutecholecysHHs• Choledocholithiasis• GallstonepancreaHHs
• AscendingCholangiHs
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AsymptomaHcCholelithiasis
• IncidentallyfoundgallstonesWITHOUTsymptoms
• 11-36%generalpopulaHon• 3%goontohavesymptomsannually• NosurgicalindicaHon
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BiliaryColic
• AKAchroniccholecysHHs• PresentaHon–episodicpost-prandialRUQpain• DuetotransientcysHcductobstrucHon• Gallbladdercanappearnormal,inflamedorcontracted/fibrosed
• Dxtests– US,CTscan– Normallabs
• Tx–cholecystectomy
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AcuteCholecysHHs• DuetopersistentcysHc
ductobstrucHnggallstones,sludge,orstricture,mass
• CanleadtoischemicornecroHcgallbladder
• PresentaHon–persistentRUQpain,N/V,SIRS,elevatedLFT’s
• Dxtests–US,HIDAscan,CT
• Tx–anHbioHcs,hydraHon,cholecystectomy
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Choledocholithiasis
• Gallstoneincommonbileduct– Primarystones–brown
– Secondarystones–cholesterol>black
– Retainedstones–immediately
– Recurrentstones
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Choledocholithiasis
• 6-12%paHentswithcholelithiasishavecholedocholithiasisaswell
• 20-25%paHents>60yowithsymptomaHcgallstonedisease
• PresentaHon–transientorpersistentRUQpain,N/V,SIRS,jaundice
• Labs–elevatedtotalbilirubin,LFT’s,leukocytosis
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SequelaeofCholedocholithiasis
• GallstonepancreaHHs
• AscendingcholangiHs
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SequelaeofCholedocholithiasis
• GallstonepancreaHHs
• AscendingcholangiHs
• PancreaHcductobstrucHon• PresentaHon–epigastricpainradiaHngtotheback/scapula,hyperamylasemia
• Tx–cholecystectomy,ERCP
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SequelaeofCholedocholithiasis
• GallstonepancreaHHs
• AscendingcholangiHs
• BilestasiswithbacterialinfecHon
• Charcot’striad–RUQpain,fever,jaundice
• Reynold’spentad–Charcot’striad+leukocytosisandAMS
• Tx–ERCP,cholecystectomy,PTC
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
• Operator-dependent
• 90%sensiHveforstones
• DilaHonofCBD>8mm
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
• Operator-dependent
• 92-100%sensiHve• PeriampullaryandpancreaHctumors
• Biopsy
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
• Riskofbleeding,cholangiHs,bileleak
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
• Tc99clearedbykupffercellsofliveràbile
• Normal–fillingofgallbladderandCBDthenduodenumat60minutes
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
• Goldstandardfordiagnosis
• 99%successful• TherapeuHc–stent,sphincterotomy
• Risks–pancreaHHs,cholagniHs,duodenalperforaHon,bleeding
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ERCP
• Cannulatepapilla• ContrastinjecHontoevaluatethebiliarytree
• IntervenHons– Sphincterotomy– Removalofgallstones– Biopsy/brushings– Stentplacement
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EvaluaHonofCholedocholithiasis• RUQUS• EUS• PercutaneoustranshepaHccholangiography
• HIDAscan• MRCP• ERCP• Intra-operaHvecholangiogram
• IndicaHons–abnormalLFT’s,pancreaHHs,jaundice,dilatedCBD,failedpre-opERCP
• Risks–bleeding,CBDinjury,pancreaHHs,infecHon
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TreatmentofCholedocholithiasis
• ObjecHves– RemoveCBDobstrucHon– Removegallbladder
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TreatmentofCholedocholithiasis
CBDstone RemovalofCBDstone
Removalofgallbladder
ERCP LaparoscopicCholecystectomy
RemovalofCBDstone
Removalofgallbladder
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TreatmentofCholedocholithiasis
CBDstone RemovalofCBDstone
Removalofgallbladder
ERCP LaparoscopicCholecystectomy
RemovalofCBDstone
RemovalofgallbladderIOC
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TreatmentofCholedocholithiasis
CBDstone RemovalofCBDstone
Removalofgallbladder
ERCP LaparoscopicCholecystectomy
RemovalofCBDstone
RemovalofgallbladderCommonbileductexploraHon
Lithotripsy
DissoluHonDrainageProcedure
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TreatmentofCholedocholithiasis
CBDstone RemovalofCBDstone
Removalofgallbladder
PercutaneousCholecystostomy
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TreatmentofCholedocholithiasis
• Lithotripsy• DissoluHon• CommonbileductexploraHon
• Drainageprocedure
THESTONEISSTUCK
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TreatmentofCholedocholithiasis
• Lithotripsy• DissoluHon• CommonbileductexploraHon
• Drainageprocedure
• ESWL–soundwaves,uncommonlyused
• Intra-corporeallaser64-97%effecHve
• Electrohydrauliclithotripsy
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TreatmentofCholedocholithiasis
• Lithotripsy• DissoluHon• CommonbileductexploraHon
• Drainageprocedure
• ursodeoxycholicacid– decreasescholesterolsaturaHonandgallbladderfuncHon
– 70%effecHve• methyltert-buthyletherMBTE
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TreatmentofCholedocholithiasis
• Lithotripsy• DissoluHon• CommonbileductexploraHon
• Drainageprocedure
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CommonBileDuctExploraHon• LaparoscopictranscysHc– <6mmstones– LargecysHcduct>4mm– CBD<6mm– Distalstone
• Laparoscopictransductal– >6mmstones– SmallcysHcduct<4mm– DilatedCBD– Proximalstone
• Open
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CommonBileDuctExploraHon
• T-tube– Longitudinalcut– Shortestroutetoskin
– Cholangiogramaper1-2weeks
– Removein2weeksifnostones
– Removein4-6weeksif+stones
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• T-tubeversusprimaryCBDclosure
• Endpoints– PosiHvebileculture– Bloodculture– DuraHonoftachycardia– DuraHonofpost-operaHvefever
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• Conclusion– PrimaryclosuremaybesuperiortoT-tubeplacement
• CriHcisms– Smallsamplesize– Fewendpoints
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TreatmentofCholedocholithiasis
• Lithotripsy• DissoluHon• CommonbileductexploraHon
• Drainageprocedure
• Transduodenalsphincteroplasty
• Choledochoduodenostomy• Choledochojejunostomy
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TransduodenalSphincteroplasty
• IndicaHons– PersistentCBDobstrucHoninNON-dilatedCBD
• Duodenotomyàcannulateampullaàsphincterotomyat11o’clockàdilatorintoCBDàclosurewithdrain
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Choledochoduodenostomy
• IndicaHons– PersistentCBDobstrucHonindilatedCBD>1.2cm
• Kocheràcholedochotomyàlongitudinalduodenotomyàside-to-sideanastomosisàdrain
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Choledochojejunostomy
• IndicaHons– PalliaHve– CBDstricture
• 45cmroux-en-Ylimbend-to-sideanastomosis
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Summary
• Bewareofcholedocholithiasis• VarietyofdiagnosHctools–invasiveandnon-invasive
• VarietyoftreatmentopHons-invasiveandnon-invasive
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QuesHonsWhichofthefollowingregardingthemanagementofcholedocholithiasisisTRUE?A. ERCPisassociatedwithhighermorbiditythan
laparoscopicCBDexploraHon.B. StoneimpacHon,periampullarydiverHcula,andMirizzi
syndromeincreasethepossibilityoffailureofERCP.C. Predictorsofsuccessfulstoneclearanceincludeproximal
stones,largestones,andnumerousstones.D. LaparoscopicCBDexploraHonislesseffecHveinclearing
commonbileductstonesthanERCP.E. SurgicalcommonbileductexploraHonrequiresplacement
ofaT-tube.
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QuesHonsWhichofthefollowingregardingthemanagementofcholedocholithiasisisTRUE?A. ERCPisassociatedwithhighermorbiditythan
laparoscopicCBDexploraHon.B. StoneimpacHon,periampullarydiverHcula,andMirizzi
syndromeincreasethepossibilityoffailureofERCP.C. Predictorsofsuccessfulstoneclearanceincludeproximal
stones,largestones,andnumerousstones.D. LaparoscopicCBDexploraHonislesseffecHveinclearing
commonbileductstonesthanERCP.E. SurgicalcommonbileductexploraHonrequiresplacement
ofaT-tube.
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QuesHons26yofemalepresentstotheEDwithRUQabdominalpainx12hours.Onexam,sheisafebrile,anicteric,andhasmildRUQtenderness,negaHveMurphy’ssign.LabsaresignificantforWBC7,AST/ALT28/32,AP331andtotalbilirubin3.2.RUQUSiscompletelynormal.WhichtestisthemostsensiHveandleastinvasivefordiagnosingcholedocholithiasis?A. HIDAscanB. CTscanC. MRCPD. ERCPE. EndoscopicUS
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QuesHons26yofemalepresentstotheEDwithRUQabdominalpainx12hours.Onexam,sheisafebrile,anicteric,andhasmildRUQtenderness,negaHveMurphy’ssign.LabsaresignificantforWBC7,AST/ALT28/32,AP331andtotalbilirubin3.2.RUQUSiscompletelynormal.WhichtestisthemostsensiHveandleastinvasivefordiagnosingcholedocholithiasis?A. HIDAscanB. CTscanC. MRCPD. ERCPE. EndoscopicUS
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