Management of bile duct stones
-
Upload
easwar-moorthy -
Category
Health & Medicine
-
view
70 -
download
6
Transcript of Management of bile duct stones
Management of CBD stonesManagement of CBD stonesin 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, ErodeEC member, IAGES South ZoneEC member, IAGES South Zone
Chairman Elect, ASI TN & P ChapterChairman Elect, ASI TN & P ChapterExaminer for MRCS (RCS of Edinburgh)Examiner for MRCS (RCS of Edinburgh)
FIAGES@ Jaipur 2016
10% of Patients with Gall stones have associated CBD stones.
CBD stones can have deadly CBD stones can have deadly consequences…consequences…
Cholangitis & SepticemiaCholangitis & Septicemia
Gall Stone PancreatitisGall Stone Pancreatitis
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
22
Biochemical DiagnosisBiochemical DiagnosisPPredicting factorsredicting factors
Liver function testsLiver function tests Bilirubin >3gmBilirubin >3gm Alkaline phosphataseAlkaline phosphatase
Transaminases: SGOT/SGPTTransaminases: SGOT/SGPTGamma GTGamma GT
Kook P et alDo 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
Radiological DiagnosisRadiological Diagnosis
US abdomenUS abdomenCT abdomenCT abdomenMRCPMRCPEUSEUSERCPERCP
33
1. US abdomen1. US abdomen
Non InvasiveDiagnostic
Dilated CBD: >6mm
Low sensitivity
Normal Ultrasound can not exclude CBD stone……
InvasiveDiagnostic
Sensitive testBut…Operator DependentAvailability?
2. Endoscopic US2. Endoscopic US
3. CT abdomen3. CT abdomen
Stomach
Aorta
Spleen
Non InvasiveDiagnostic
Mass
Liver
CBD stone
Non InvasiveDiagnostic
Test of Choice
4. MRCP4. MRCP
Bile duct with stone
Pancreatic duct
5. ERCP For Bile Duct Stones5. ERCP For Bile Duct Stones
TreatmentOf
Choice
InvasiveEssentially Therapeutic
44
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
What will you do prior to Lap chole?
55
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 H/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
What will you do next?
66
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
ERCP TeamERCP Team
•Endoscopy Team
•Radiology Team
•Anaesthetic Team
•Nursing Team
ERCPERCP
ERCP: Diagnostic aspectsERCP: Diagnostic aspectsImpacted stone
Pouring out Pus
Road Map
Side Viewing Scope & AccessoriesSide Viewing Scope & Accessories
Balloon, Basket & Biopsy forceps…
ERCP : Therapeutic AdvantageERCP : Therapeutic Advantage
Sphincterotomy
Balloon Sweep
Lithotripsy
Selective Cannulation Sphincteroplasty
ERCP: Multiple CBD stonesERCP: Multiple CBD stones
•Sphincterotomy•Balloon Sweep•Dormia
About ERCPAbout ERCPA word of Caution!A word of Caution!
Only used as Only used as therapeutictherapeutic modality modalityDuct 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%
77
What is the standard of Care for this lady…
Pre operative DiagnosisPre operative DiagnosisStandard of CareStandard of Care
Pre op ERCP……………Lap cholePre op ERCP……………Lap choleOpen Chole and CBD explorationOpen Chole and CBD exploration
Lap chole…………Post op ERCPLap chole…………Post op ERCPLap chole and Lap CBD explorationLap chole and Lap CBD exploration
ConsiderLocal resources and expertiseMorbidity and cost effectiveness
88
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 : >4mmSize of cystic duct : >4mm Cystic duct entranceCystic duct entrance
HowHow CholangiogramCholangiogram DilatationDilatation CholedochoscopyCholedochoscopy Extraction of stonesExtraction of stones
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
Lap CBD ExplorationLap CBD ExplorationCase SelectionCase SelectionExpertiseExpertiseEquipmentsEquipments
Lap suturing Lap suturing C arm and cholangiogramC arm and cholangiogramStone retrival gadgetsStone retrival gadgets
Dormia/Balloon/ Choangioscope Vs NephroscopeDormia/Balloon/ Choangioscope Vs NephroscopeT tube/StentT tube/StentAdditional monitorsAdditional monitors
Lap CBD Exploration: Lap CBD Exploration: OptionsOptions
•EHL/Laser Lithotripsy•Stent/T tube/Primary suture•Choledocho duodenostomy
Choledocho-duodenostomyCholedocho-duodenostomyIndication:Indication: CBD > 2cm/multiple stones and sludge with stricture lower CBD > 2cm/multiple stones and sludge with stricture lower
end/elderly ptend/elderly ptOperation: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
99
Intra operative diagnosis of Bile duct stonesIntra operative diagnosis of Bile duct stones(During Lap Chole)(During Lap Chole)
Operative CholangiogramOperative CholangiogramRoutineRoutineSelectiveSelective
Suspected CBD stoneSuspected CBD stoneUnclear anatomyUnclear anatomy
Intra operative UltrasoundIntra operative Ultrasound
Management of CBD stonesManagement of CBD stonesAcc to Time of DiagnosisAcc to Time of Diagnosis
Pre-operative Pre-operative Intra- operativeIntra- operativePost -operativePost -operative
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
POST - OPERATIVE DIAGNOSISPOST - OPERATIVE DIAGNOSIS(Minus GB)(Minus GB)
ERCPERCPMRCPMRCPT tube CholangiogramT tube Cholangiogram
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
MRCP1010
MRCP
Non InvasiveDiagnostic
CBD
Stone
Test Of
Choice
ERCP : Your diagnosis?ERCP : Your diagnosis?
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 amylaseWas 2016 units. US abdomen showed multiple small gall stones and dilated CBDAnd enlarged pancreas. In view of unabated pain, fever, and jaundice, the patientUnderwent ERCP.
1111
Severe Biliary PancreatitisSevere Biliary PancreatitisRole of Early ERCPRole of Early ERCP
Neoptolemos et alLancet 2: 976-983, 1988Fan et alN Engl J Med 328: 228-232, 1993
•Less morbidity•Shorter hospital stay•Trend towards lower mortality?
Recent Advances…Recent Advances… LithotripsyLithotripsy
MechanicalMechanical Electro hydraulicElectro hydraulic LaserLaser
CholedochoscopyCholedochoscopy Spy GlassSpy Glass
Rendezvous techniqueRendezvous technique Bioluminence CholangiogramBioluminence Cholangiogram
Advances in ERCPAdvances in ERCPMother & Baby CholangioscopyMother & Baby Cholangioscopy
Spyglass choledochoscopyAdvances in ERCPAdvances in ERCP
Novel way of treating difficult bile duct stones…
ConclusionConclusionMinimal Access-Maximum SuccessMinimal Access-Maximum Success
MRCP is the Test of Choice MRCP is the Test of Choice ERCP is the Treatment of ChoiceERCP is the Treatment of ChoiceLap CBD exploration requires adequate Lap CBD exploration requires adequate
training and appropriate equipmentstraining and appropriate equipmentsBile ducts stones need special attentionBile ducts stones need special attention