SUNY Downstate Medical Center Kings County Hospital
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1 Management of Choledocholithiasis SUNY Downstate Medical Center Kings County Hospital Department of Surgery Grand Rounds Kiyanda Baldwin October 22, 2009
2 Case Presentation 43 y/o F c/o jaundice x 3 days associated with nausea & anorexia PMH: HTN, CVA PSH: c-section x2 Meds: norvasc All: nkda SH: tobacco 1ppd x 20yrs quit 10 yrs ago, denies illicit drug or etoh use
3 Physical Exam Afebrile, hemodynamically normal Scleral icterus Abd soft, obese, NT, +BS no rebound/guarding, no masses appreciated Otherwise wnl
4 Labs Wbc 6.3 Ast/Alt 237/335, AP/Tb 451/12.9 Am/Lip 340/880
5 Radiology U/S cholelithiasis, CBD 9mm MRCP: gallstones, CBD 2.4cm, Multiple CBD defects up to 13cm 1.3cm ERCP, sphincterotomy, 10Fr. 11cm stent placement, unable to extract stones
6 Hospital Course HD 2 amylase & lipase decrease by half Pt optimized for OR HD 10: ex-lap, cholecystectomy, CBD exploration with stone extraction, choledochoduodenostomy
7 Ex-Lap Lap, Cholecystectomy R. subcostal incision Contracted intrahepatic gallbladder resected in retrograde fashion Cystic duct almost obliterated, GB transected at its base, CBD ~4cm
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9 CBD Exploration Kocher maneuver, duodenal mobilization 1.5cm longitudinal incision made in CBD CBD stent removed Large distal stone extracted w/ atraumatic forceps Smaller common hepatic and bile duct stones extracted with fogarty catheter
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12 Choledochoduodenostomy Longitudinal incision made in 3 rd portion of duodenum Diamond-shaped single layer side to side anastomosis w/ 4-0 vicryl No. 10 JP left near anastomosis Pt extubated in OR and tolerated procedure well
13 Postoperative Course POD 2: clear liquids POD 3: full bowel function started on reg diet POD 4: discharged home POD 11: outpt, doing well
14 ?QUESTIONS?
15 Management of Choledocholethiasis h l h
16 Goals Tools in diagnosis i of choledocholithiasis h li hi i Treatment t ERCP Cholangiogram and duct exploration Choledochal drainage procedures Duct exploration vs postop ERCP Biliary stents?
17 Etiology Bilirubin, 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 bilirubin, soft & easy to crumble Biliary stasis & bacteria Increased in SE asian populations Current Surgical Therapy 9th Edition Cameron 2008
18 Choledocholethiasis 6-12% of pts w/ GB stones 20-25% 25% of pts >60 y/o w/ symptomatic GB stones Secondary stones-cholesterol, primary- brown pigment Primary-associated associated w/ stricture, stenosis, tumors, secondary stones Schwartz s Principles of Surgery, 8th Edition 2005
19 Manifestations Biliary colic Gallstone pancreatitis Ascending cholangitis Elevated bilirubin, alk phos, transaminases; 1/3 normal LFTs Schwartz s Principles of Surgery, 8th Edition 2005
20 Radiology U/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/s Schwartz s Principles of Surgery, 8th Edition 2005
21 Treatment ERCP w/ sphincterotomy & duct clearance followed by lap chole Lap chole w/ postop ERCP & sphincterotomy (failure rate 4-10%) Cholecystectomy t w/ intraop cholangiogram Current Surgical Therapy 9th Edition Cameron 2008
22 ACS Surgery: Principles & Practice
23 ERCP 1968 first ERCP Side viewing endoscope CBD cannulated & cholangiogram under fluoro, >90% successful 1973 first sphincterotomy Sphincteromy, balloon sphincteroplasty (6-8mm, 22% failure rate), basket sweep Current Surgical Therapy 9th Edition Cameron 2008
24 ERCP
25 Intraoperative Cholangiogram g Schwartz s Principles of Surgery, 8th Edition 2005
26 Intraop Managemnt of CBD Stones Flush small stones after relaxing sphincter of Oddi w/ 1-2mg glucagon Transcystic duct exploration w/ fluoroscopic balloon catheterization and wire basket sweep Indications: cbd 6mm, stones are distal to cystic- CBD junction, cystic duct >4mm, <6-8 CBD stones If stones 4-8mm, use choledochoscope (endoscopic transcystic CBD exploration) If stone >1cm lap CBD exploration w/ choledochotomy & 10-14Fr T-tube ACS Surgery: Principles & Practice 2009
27 Transcystic Duct Exploration ACS Surgery: Principles & Practice 2009
28 Open CBD exploration Indications: failed ERCP, failed laparoscopic attempts, surgeon s comfort Kocher maneuver 1-2cm incision in CBD ant wall w/ 2 stay sutures Respect arterial supply at 3 & 9 o clock Use forceps, fogarty cath, wire baskets ACS Surgery: Principles & Practice 2009
29 T-tube management Rpt cholangiogram through T-tube No stones clamp tube & remove in 2 wks Retained stones stone retrieval after 4-6 wks ACS Surgery: Principles & Practice 2009
30 Success & M/M Rates Transcystic CBD exploration Success 71-98% Morbidity 0-14% (cystic (y duct leak, bile duct perf, pancreatitis), retained stones 2-5% Lap CBD exploration w/ cholodochotomy Success 85-97% Morbidity 3-16% Current Surgical Therapy 9th Edition Cameron 2008
31 Choledochal Drainage Procedures Transduodenal sphincterotomy Choledochoduodenostomy Choledochojejunostomy h j
32 Indications for Choledochal Drainage Procedures Irremovable, impacted, distal CBD stones Markedly dilated CBD, >1.5cm Distal duct obstruction from tumor or stricture Recurrence after previous duct exploration Schwartz s Principles of Surgery, 8th Edition 2005 Maingot s Adominal Operations 11th Edition 2007
33 Transduodenal Sphincterotomy Useful for stone impaction in ampulla of Vater, 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 clock Maingot s Adominal Operations 11th Edition 2007
34 Transduodenal Sphincterotomy Sphincterotomy at 11 o clock 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
35 Transduodenal Sphincterotomy
36 Choledochoduodenostomy Indications Recurrent stones Impacted or giant stones Biliary sludge Ampullary stenosis Funnel syndrome Maingot s Adominal Operations 11th Edition 2007
37 Choledochoduodenostomy CBD at least 1.2cm Kocherize duodenum 1-2cm distal choledochotomy Clear CBD stones Longitudinal duodenotomyd Side to side single-layered anastomosis w/ absorbable suture Place drain Maingot s Adominal Operations 11th Edition 2007
38 Choledochoduodenostomy
39 Choledochoduodenostomy Morbidity/mortality: 23 & 3% Morbidities: Cholangitis 0-6% Sump syndrome Wound infection, anastomotic leak, intraabdominal abscess (most important factor: large distal stoma) Mortalities: usually medical PE, MI, heart failure 70-80% asymptomatic matic after 5 yrs Maingot de Aretxabala X, Bahamondes JC. Choledochoduodenostomy for common bile duct stones. World J Surg 1998;22: , Maingot s Adominal Operations 11th Edition 2007
40 Choledochojejunostomy Retrocolic 45-60cm roux-en-y w/ end to side anastomosis Interrupted absorbable b bl Sutures Protects against intestinal reflux & secondary cholangitis i Leave a drain
41 Randomised trial of laparoscopic exploration of common bile duct versus postoperative endoscopic retrograde cholangiography for common bile duct stones M Rhodes, L Sussman, L Cohen, M P Lewis Norfolk and Norwich Trust Hospital, UK Intention to treat analysis Primary end points: duct clearance, morbidity, OR time, hospital stay THE LANCET Vol 351 January 17, 1998
42
43 LECBD vs Postop ERCP LECBD 7 pts w/ morbidities 1 open, 2 readmissions pain control, 3 bile leaks from stents, 1 urinary retention ERCP 6 pts w/ morbidities 1 postop hemorrhage, 1 bile leak, 3 post sphincterotomy bleeding, 1 retained stone
44 LECBD vs Postop ERCP
45 Biliary Stents DiFronzo et al, Kaiser Permanente, pts w/ biliary-enteric anastomosis w/o stent 1 case, 1% anastomotic leak Innes et al, Ohio State, pts w/ reconstructive biliary-enteric anastomosis due to stricture w/o stent 4 complications: 1 fistula, 1 abscess, 2 reccurrent stricture
46 Summary To detect CBD stones U/S, MRCP, ERCP, Cholangiogram To remove stones ERCP, transcystic duct exploration, CBD exploration (irrigate, balloon, basket) Biliary Drainage Procedures Transduodenal sphincterotomy, choledochoduodenostomy, h d d choledochojejunostomy There is a role for operative CBD explorations Biliary Stents?
47 References 1. Schwartz s Principles of Surgery, 8th Edition Current Surgical Therapy 9th Edition Cameron ACS Surgery: Principles & Practice Maingot s Adominal Operations 11th Edition Zollinger s Atlas of Surgical Operations 8 th Edition Fitzgibbons RJ, Gardner GC: Laparoscopic surgery and the common bile duct. World J Surg 2001; 25: Hungness ES, Soper NJ: Management of common bile duct stones. J Gastrointest Surg 2006; 10: 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: DiFronzo LA, Egrari S, O'Connell TX. Safety and durability of single-layer, stentless, biliary-enteric anastomosis. Am Surg 1998;64: 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:
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