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