Management ofCommon Bile Duct

stones

Dr. Daniel TM ChungDepartment of Surgery, Pamela Youde Nethersole Eastern Hospital, HK East Cluster

Joint Hospital Surgical Grand Round Sept., 2008

Background10%-18% of patients undergoing cholecystectomy have CBD stones

Before the advent of ERCP/laparoscopy, patients with choledocholithiasis required open surgical treatment

Development of endoscopy and laparoscopy, choices become more

Nowadays…The optimal treatment of choledocholithiasis is still a controversial issue

Stone size

Number of stone

Timing of discover of CBD stone

Size of cystic duct / CBD

Patient’s general condition

Previous surgery

Availability of expertise

Facilities

Objective

To discuss various techniques for CBD clearance

MRCP

Intra-op ERCP +/- ES

Lap. Cholecystectomy +/- IOC +/- open

USG

Suspicion of CBD stones

Stone Clearance

Post-op ERCP +/- ES

ECBD (laparoscopic / open approach)

Preoperative ERCP +/- ES

ERCP(patient’s condition)

Preoperative Endoscopic Therapy

Elderly / Debilitated patientsJaundiced / cholangitis / severe pancreatitis75-84% of patient remains symptom free up to 70-month follow-up

Vazquez-Inglesias JL et al. Surg Endosc 2004

Schreurs WH et al. Dis Surg 2004

DisadvantagesLess patient compliance

Two-session treatment

Longer hospital stay

Risk of ERCP

Routine pre-op ERCP: Up to 61% of patients with suspected common duct stones undergo an unnecessary ERCP with its associated morbidityNataly Y et al. ANZ J Surg 2002

Postoperative endoscopic therapy

Definitive treatment of CBD stones when:Lap ECBD failed to clear the duct

Retained stones are discovered postoperatively

Incidence 2.5%

Comorbidities make a prolonged operation risky

CBD small and prone to post-op stricture

Disadvantage: possibility of failure in cannulation of CBD / removal of CBD stones

ECBD (Open/Laparoscopic approach)

Endoscopically difficult stones:Stones > 15mm

Multiple stones

Impacted stones

Distorted anatomyTortuous bile duct

Duodenal diverticulum

Billroth II reconstruction / surgical duodenotomy

Laparoscopic ECBDPotential benefit: minimally invasive, shorter hospital stay, less pain, better cosmetic result

Significantly reduced hospital stay compared with pre-op ERCP/ES + LC

100% success rate in salvaging failed pre-op ERCP

Transcystic technique vs. choledochotomy

Cuschieri A et al. Surg Endoc 1999

Tai CK, Tang CN et al. Surg Endosc 2004

Transcystic techniqueSuccessful ductal clearance in 80–90% of patients

Complication rate: 5-10%

Mortality rate: 0-2%

Duration of hospitalization: 1-2 days

Main advantage: avoid choledochotomy

Cuschieri A et al. Surg Endosc 1999

Rojas-Ortega S et al. J Gastrointest Surg 2003

Thompson MH et al. Br J Surg 2002

Transcystic technique Choledochotomy

(+/- choledochoscopy)

Few in number of stones Numerous stones

< 1 cm in size Large stones

Situated distal to cystic duct entry

Stones in CHD

Laparoscopic Exploration of the Common Bile Duct: 10-year

Experience of 174 Patients from a Single Centre

1995-20051144 ES / 22 open ECBD / 174 lap ECBD M:F = 71:103Mean age: 63 (SD = 16)156 choledochotomies / 18 transcystic duct exploration

Tang and Li, HKMJ 2006; 12:191-6

Indications of LECBD Patients no.

n=174

Young patient (<60 years) with concomitant gallstones and CBD stones

68 (39%)

Previous failed ERCP 59 (34%)

Large (>2cm) or multiple CBD stones

40 (23%)

RPC (for drainage choledochoenterostomy)

34 (20%)

Morbidity / Mortality Patients No.

Overall Morbidity 34 (19.5%)

Bile leak / stent migration / collection 15 (8.6%)

Residual stones 14 (8.0%)

Wound infection / bleeding 4 (2.3%)

Bile duct injury 4 (2.3%)

Blocked stent 2 (1.1%)

Cholangitis 2 (1.1%)

Retained stone inside peritoneal cavity 1 (0.6%)

Duodenal injury 1 (0.6%)

Intra-abdominal collection 1 (0.6%)

Intestinal obstruction 1 (0.6%)

Mortality (secondary to bile leak and collection) 1 (0.6%)

Cuschieri Sgourakis

Pre-op ES LC+LCBDE

P value Pre-op ES LC+LCBDE

P value

n=150 N=150 N=36 N=42

Morbidity 12.8% 15.8% 0.54 13% 17% <0.87

Mortality 1.5% 0.75% NS 2% 2% NS

CBD clearance (% of operations)

84% 84% 0.96 86% 84% NS

Length of hospital stay (mean days)

9 6 <0.05 7.4 9 0.07

Edward H. Philips et al. J Gastrointest Surg, 2008

Nethanson Rhodes

LCBDE (choledo-chotomy)

Post-op ES P value LCBDE (transcystic)

Post-op ES P value

n=43 n=43 n=40 n=40

Primary ductal clearance

100% 74% 0.20 75% 75% NA

Final ductal clearance

100% 100% NS 100% 93% NA

Morbidity 17% (14.6% bile leak)

13% NS 0 0 NA

Mortality 0 0 NS 0 0 NA

Length of hospital stay (mean days)

6.4 7.7 0.57 1 3.5 NA

Intra-operative ERCP: Advantages

Treatment in one sessionAvoids overestimation of patients selected for pre-op ERCP on the basis of imaging as well as biochemical and clinical criteriaPossible to carry out main bile duct laparoscopic or open exploration during same procedure in case of failureCatheterization and positioning of papillotom facilitated by a rendezvous between guidewire inserted through cystic duct into duodenum and the papillotom itself

Rendezvous

Intra-operative ERCP: Disadvantage

Increase in laparoscopic cholecystectomy surgery duration

Logistic difficulties in the procedure organization

May require multiple units (e.g. surgeons and endoscopists)

Experts required

Supine position for ERCP

Preoperative Endoscopic Sphincterotomy versus

Laparoendoscopic Rendezvous in Patients with Gallbladder and Bile

Duct Stones

Prospective, randomized trial

91 elective patients with cholelithiasis and CBD stones

Diagnosed at MRC

Mario Morino et al. Annals of Surgery, 2006

Group I Group II

Pre-op ERCP +ES followed by LC

LC +intraop ERCP +ES

No. of patients (n) 45 46

CBD clearance 80% 95.6% P=0.06

Morbidity rate 8.8% 6.5% NS

Mortality rate 0% 0%

Hospital Stay (day) 8.0 4.3 P < 0.0001

Mean total cost (Euro)

3834 2829 P < 0.05

Two-stage Treatment with Preoperative ERCP compared with

Single-stage Treatment with Intraoperative ERCP for Patients with

Symptomatic Cholelithiasis with Possible Choledocholithiasis

Rabago LR et al. Endoscopy, 2006

Prospective randomized study

Success rate: similar

Frequency of residual CBD stones, conversion rate, surgical morbidity: no differences

Intra-op ERCP group: less morbidity, a shorter hospital stay, reduced costs

Our Hospital’s experience:

LC + intra-op ERCPJune 2006 - September 2008n=12 (M:F = 9:3)Mean Age = 61.4 (22 - 79)Indications:

Cholangitis: 11Biliary pancratitis: 1

Cannulation rate: 100%

Stone clearance: 66% (8 cases)2 need conversion to laparotomy + ECBD

2 need post-op ERCP

MorbidityNo major surgical complications

1 case of severe pneumonia

Mortality: 0%

Post-op hospital stay: mean 5.75 days (1 – 14 days)

Operation Timing

Mean operation time:134.18 minutes (61 – 215 minutes)

Mean operation time (June 2006 – Feb 2008)

150.83 minutes (120 – 215 minutes)

Mean operation time (Feb – Sept 2008)

114.2 minutes (61 – 210 minutes)

Intraoperative ERCPReasons for improvement in surgical time:

Improvement in facilitiesBetter cooperations among surgeons / endoscopists, nurses and other theatre staffsMastering of techniques

Surgical versus Endoscopic Treatment of Bile Duct

Stones

3974 articles reviewed

13 trials randomised 1251 patients8 trials (n=760) (ERCP vs open surgical clearance)

3 trials (n=425) (pre-op ERCP vs lap clearance)

2 trials (n=166) (post-op ERCP vs lap clearance)

Martin DJ et al. Cochrane Database Syst Rev. 2006

A significantly increased number of total procedures per patient was seen in ERCP armsERCP was less successful than open surgery in stone clearance; with a tendency towards higher mortalityLap CBD stone clearance was as effective as pre- or post-operative ERCP; no significant difference in morbidity and mortalityLaparoscopic trials: shorter hospital stays in surgical armsInsufficient data reported for cost analysisConclusions:

… In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones…

ConclusionControversial

Depends on expertise available, instruments, personal experience, patient condition