role of ERCP and laparoscopy in managing cbd stones

2. Management of CBD stonesManagement of CBD stones
in the Era of Laparoscopyin the Era of Laparoscopy
Dr.S.EaswaramoorthyDr.S.Easwaramoorthy
MS FRCS (Eng), FRCS (Edin), FRCS (Glasgow)MS FRCS (Eng), FRCS (Edin), FRCS (Glasgow)
Consultant Surgeon, Lotus Hospital, ErodeConsultant Surgeon, Lotus Hospital, Erode
EC member, IAGES South ZoneEC member, IAGES South Zone
Chairman Elect, ASI TN & P ChapterChairman Elect, ASI TN & P Chapter
Examiner for MRCS (RCS of Edinburgh)Examiner for MRCS (RCS of Edinburgh)
FIAGES@ Jaipur 2016

3. 10% of Patients with Gall stones have associated CBD stones.

4. CBD stones can have deadlyCBD stones can have deadly
consequences…consequences…
 Cholangitis & SepticemiaCholangitis & Septicemia
 Gall Stone PancreatitisGall Stone Pancreatitis

6. CBD Stone: PresentationCBD Stone: Presentation
 CholangitisCholangitis
 Charcot’s triadCharcot’s triad
 Intermittent painIntermittent pain
 Intermittent feverIntermittent fever
 Intermittent jaundiceIntermittent jaundice
 Reynold’s PentadReynold’s Pentad
 HypotentionHypotention
 ConfusionConfusion
 Obstructive JaundiceObstructive Jaundice
 PancreatitisPancreatitis
 AsymptomaticAsymptomatic

7. 22

8. Biochemical DiagnosisBiochemical Diagnosis
PPredicting factorsredicting factors
Liver function testsLiver function tests
Bilirubin >3gmBilirubin >3gm
Alkaline phosphataseAlkaline phosphatase
Transaminases: SGOT/SGPTTransaminases: SGOT/SGPT
Gamma GTGamma GT
Kook P et al
Do Pre operative indicators predict the presence of CBD stones during lap chole?
Am J Surg, 495-499, 1996
Normal Liver profile does not exclude CBD stones

9. Radiological DiagnosisRadiological Diagnosis
 US abdomenUS abdomen
 CT abdomenCT abdomen
 MRCPMRCP
 EUSEUS
 ERCPERCP

10. 33

11. 1. US abdomen1. US abdomen
Non Invasive
Diagnostic
Dilated CBD: >6mm
Low sensitivity
Normal Ultrasound can not exclude CBD stone……

12. Invasive
Diagnostic
Sensitive test
But…
Operator Dependent
Availability?
2. Endoscopic US2. Endoscopic US

13. 3. CT abdomen3. CT abdomen
Stomach
Aorta
Spleen
Non Invasive
Diagnostic
Mass
Liver
CBD stone

14. Non Invasive
Diagnostic
Test of Choice
4. MRCP4. MRCP
Bile duct with stone
Pancreatic duct

15. 5. ERCP For Bile Duct Stones5. ERCP For Bile Duct Stones
Treatment
Of
Choice
Invasive
Essentially Therapeutic

16. 44

17. Pre operative risk assessmentPre operative risk assessment
 High risk (>50%):High risk (>50%): ERCPERCP
 Clinical Jaundice, CholangitisClinical Jaundice, Cholangitis
 Bilirubin > 3mgmBilirubin > 3mgm
 CBD > 6mm, Stone in CBDCBD > 6mm, Stone in CBD
 Moderate risk ( 10-50%):Moderate risk ( 10-50%): MRCP/EUS/ICMRCP/EUS/IC
 H/O of Jaundice or pancreatitisH/O of Jaundice or pancreatitis
 Multiple small stones in GBMultiple small stones in GB
 Raised Al.Phosphatase and bilirubinRaised Al.Phosphatase and bilirubin
 Low risk ( < 5%):Low risk ( < 5%):
 Normal Liver profileNormal Liver profile
 US: Normal CBD. Large stone in GBUS: Normal CBD. Large stone in GB
 No H/O of Jaundice or pancreatitisNo H/O of Jaundice or pancreatitis
ASGE Standards of Practice Committee et al 2010

18. What will you do prior to Lap chole?
55

19. Pre operative risk assessmentPre operative risk assessment
 High risk (>50%):High risk (>50%): ERCPERCP
 Clinical Jaundice, CholangitisClinical Jaundice, Cholangitis
 Bilirubin > 3mgmBilirubin > 3mgm
 CBD > 6mm, Stone in CBDCBD > 6mm, Stone in CBD
 Moderate risk ( 10-50%):Moderate risk ( 10-50%): MRCP/EUS/ICMRCP/EUS/IC
 H/O of Jaundice orH/O of Jaundice or pancreatitispancreatitis
 Multiple small stones in GBMultiple small stones in GB
 Raised Al.Phosphatase and bilirubinRaised Al.Phosphatase and bilirubin
 Low risk ( < 5%):Low risk ( < 5%):
 Normal Liver profileNormal Liver profile
 US: Normal CBD. Large stone in GBUS: Normal CBD. Large stone in GB
 No H/O of Jaundice or pancreatitisNo H/O of Jaundice or pancreatitis
ASGE Standards of Practice Committee et al 2010

20. What will you do next?
66

21. Pre operative risk assessmentPre operative risk assessment
 High risk (>50%):High risk (>50%): ERCPERCP
 Clinical JaundiceClinical Jaundice,, CholangitisCholangitis
 Bilirubin > 3mgmBilirubin > 3mgm
 CBD > 6mmCBD > 6mm, Stone in CBD, Stone in CBD
 Moderate risk ( 10-50%):Moderate risk ( 10-50%): MRCP/EUS/ICMRCP/EUS/IC
 H/O of Jaundice or pancreatitisH/O of Jaundice or pancreatitis
 Multiple small stones in GBMultiple small stones in GB
 Raised Al.Phosphatase and bilirubinRaised Al.Phosphatase and bilirubin
 Low risk ( < 5%):Low risk ( < 5%):
 Normal Liver profileNormal Liver profile
 US: Normal CBD. Large stone in GBUS: Normal CBD. Large stone in GB
 No H/O of Jaundice or pancreatitisNo H/O of Jaundice or pancreatitis
ASGE Standards of Practice Committee et al 2010

23. ERCP TeamERCP Team
•Endoscopy Team
•Radiology Team
•Anaesthetic Team
•Nursing Team

24. ERCPERCP

25. ERCP: Diagnostic aspectsERCP: Diagnostic aspects
Impacted stone
Pouring out Pus
Road Map

26. Side Viewing Scope & AccessoriesSide Viewing Scope & Accessories
Balloon, Basket & Biopsy forceps…

27. ERCP : Therapeutic AdvantageERCP : Therapeutic Advantage
Sphincterotomy
Balloon Sweep
Lithotripsy
Selective Cannulation Sphincteroplasty

28. ERCP: Multiple CBD stonesERCP: Multiple CBD stones
•Sphincterotomy
•Balloon Sweep
•Dormia

29. About ERCPAbout ERCP
A word of Caution!A word of Caution!
 Only used asOnly used as therapeutictherapeutic modalitymodality
 Duct Cannulation rate: 95%Duct Cannulation rate: 95%
 Duct Clearance rate : 90%Duct Clearance rate : 90%
 ComplicationsComplications
Pancreatitis: 5%Pancreatitis: 5%
Bleeding : 3%Bleeding : 3%
Perforation: 1%Perforation: 1%
 MortalityMortality: 1%: 1%

30. 77
What is the standard of Care for this lady…

31. Pre operative DiagnosisPre operative Diagnosis
Standard of CareStandard of Care
 Pre op ERCP……………Lap cholePre op ERCP……………Lap chole
 Open Chole and CBD explorationOpen Chole and CBD exploration
 Lap chole…………Post op ERCPLap chole…………Post op ERCP
 Lap chole and Lap CBD explorationLap chole and Lap CBD exploration
Consider
Local resources and expertise
Morbidity and cost effectiveness

32. 88

33. Laparoscopic management of CBD stonesLaparoscopic management of CBD stones
1. Transcystic approach1. Transcystic approach
 WhenWhen
 Size of the stones : smallSize of the stones : small
 Size of cystic duct :Size of cystic duct :
>4mm>4mm
 Cystic duct entranceCystic duct entrance
 HowHow
 CholangiogramCholangiogram
 DilatationDilatation
 CholedochoscopyCholedochoscopy
 Extraction of stonesExtraction of stones

34. 2. Lap CBD Exploration2. Lap CBD Exploration
•Exposure of CBD
•Vertical Choledochotomy
•Squeeze technique
•Flushing Techniques
•Balloon sweep technique
•Basket technique
•Choledochoscopic technique
WhenWhen
 Dilated ductDilated duct
 Large stonesLarge stones
 Also proximal stonesAlso proximal stones

35. Lap CBD ExplorationLap CBD Exploration
 Case SelectionCase Selection
 ExpertiseExpertise
 EquipmentsEquipments
Lap suturingLap suturing
C arm and cholangiogramC arm and cholangiogram
Stone retrival gadgetsStone retrival gadgets
Dormia/Balloon/ Choangioscope Vs NephroscopeDormia/Balloon/ Choangioscope Vs Nephroscope
T tube/StentT tube/Stent
Additional monitorsAdditional monitors

36. Lap CBD Exploration:Lap CBD Exploration: OptionsOptions
•EHL/Laser Lithotripsy
•Stent/T tube/Primary suture
•Choledocho duodenostomy

37. Choledocho-duodenostomyCholedocho-duodenostomy
Indication:Indication:
 CBD > 2cm/multiple stones and sludge with stricture lowerCBD > 2cm/multiple stones and sludge with stricture lower
end/elderly ptend/elderly pt
Operation:Operation:
 Open Vs LapOpen Vs Lap
 Vertical supra-duodenal choledochotomyVertical supra-duodenal choledochotomy
 Longitudinal duodenotomy : 1st partLongitudinal duodenotomy : 1st part
 Interrupted 3-0 vicrylInterrupted 3-0 vicryl

38. 99

39. Intra operative diagnosis of Bile duct stonesIntra operative diagnosis of Bile duct stones
(During Lap Chole)(During Lap Chole)
Operative CholangiogramOperative Cholangiogram
RoutineRoutine
SelectiveSelective
Suspected CBD stoneSuspected CBD stone
Unclear anatomyUnclear anatomy
Intra operative UltrasoundIntra operative Ultrasound

40. Management of CBD stonesManagement of CBD stones
Acc to Time of DiagnosisAcc to Time of Diagnosis
Pre-operativePre-operative
Intra- operativeIntra- operative
Post -operativePost -operative

41. Standard of CareStandard of Care
 Lap chole/Post op ERCPLap chole/Post op ERCP
 Lap chole/Lap CBD explorationLap chole/Lap CBD exploration
 Convert to Open chole and CBD explorationConvert to Open chole and CBD exploration

42. POST - OPERATIVE DIAGNOSISPOST - OPERATIVE DIAGNOSIS
(Minus GB)(Minus GB)
 ERCPERCP
 MRCPMRCP
 T tube CholangiogramT tube Cholangiogram

43. 60/M with 4 months history of fever and abdominal pain on and off.
H/o cholecystectomy 10 years ago.
He also gave history Of passing dark urine at least in 2 occasion.
Following US , the patient underwent MRCP

44. MRCP
1010

45. MRCP
Non Invasive
Diagnostic
CBD
Stone
Test
Of
Choice

46. ERCP : Your diagnosis?ERCP : Your diagnosis?

47. A case of Gall Stone PancreatitisA case of Gall Stone Pancreatitis
Needle Knife Sphincterotomy
Impacted stone at Ampula
34/M presented with severe abdominal and
back pain for 3 days. Serum amylase
Was 2016 units. US abdomen showed
multiple small gall stones and dilated CBD
And enlarged pancreas. In view of unabated
pain, fever, and jaundice, the patient
Underwent ERCP.

48. 1111

49. Severe Biliary PancreatitisSevere Biliary Pancreatitis
Role of Early ERCPRole of Early ERCP
Neoptolemos et al
Lancet 2: 976-983, 1988
Fan et al
N Engl J Med 328: 228-232, 1993
•Less morbidity
•Shorter hospital stay
•Trend towards lower mortality?

51. Recent Advances…Recent Advances…
 LithotripsyLithotripsy
 MechanicalMechanical
 Electro hydraulicElectro hydraulic
 LaserLaser
 CholedochoscopyCholedochoscopy
 Spy GlassSpy Glass
 Rendezvous techniqueRendezvous technique
 Bioluminence CholangiogramBioluminence Cholangiogram

52. Advances in ERCPAdvances in ERCP
Mother & Baby CholangioscopyMother & Baby Cholangioscopy

53. Spyglass choledochoscopy
Advances in ERCPAdvances in ERCP

54. Novel way of treating difficult bile duct stones…

55. ConclusionConclusion
Minimal Access-Maximum SuccessMinimal Access-Maximum Success
 MRCP is the Test of ChoiceMRCP is the Test of Choice
 ERCP is the Treatment of ChoiceERCP is the Treatment of Choice
 Lap CBD exploration requires adequateLap CBD exploration requires adequate
training and appropriate equipmentstraining and appropriate equipments
 Bile ducts stones need special attentionBile ducts stones need special attention