Surgical Management of Choledocholithiasis Management... · 2016-11-10 · Quesons Which of the following regarding the management of choledocholithiasis is TRUE? A. ERCP is associated

SurgicalManagementofCholedocholithiasis

UniversityHospitalofBrooklynL.YukoShimotake,MDNovember10,2016

www.downstatesurgery.org

CasePresentaHon

•  81yomalepresentedtoambulatorysurgeryforroboHccholecystectomy.

•  PMHx:Hypertension,CVA,CAD•  PSHx:Denies•  Allergies:NKDA•  SocialHx:Historyofalcoholism(quitin6monthsago),deniescigareResorillicitdruguse


CasePresentaHon

•  Previousadmission–3monthsprior– Choledocholithiasis– GallstonepancreaHHs– AscendingcholangiHs

12.9837.9

13344 1359717

3.6281.08127

6.454439

2.85749.8

Amylase295Lipase769


CasePresentaHon•  CTA/P–  CholelithiasisandcholedocholithiasiscausingobstrucHon

–  Secondaryintra-andextra-hepaHcductaldilataHon–  PancreaHcductaldilataHon–  CBD1.4cm

•  IntervenHon–  IVanHbioHcs–  ERCP

•  removalof2largegallstones•  stentplacement


CasePresentaHon

•  OperaHon– RoboHcconvertedtoopencholecystectomy– CommonbileductexploraHon– Omentalpatchofduodenotomy


CasePresentaHon

•  Intra-operaHvefindings:– Denseadhesionsinvolvingtransversecolonandduodenum

– Contractedgallbladder

– Choleduodenalfistula–  ImpactedstoneswithintheCBD


CommonBileDuctExploraHon•  ExposeanteriorCBD•  Lateralstaysutures•  VerHcalincisionoftheCBD•  IrrigaHonwithcatheter•  Ballooncatheterfogerty•  Basket•  Stoneforceps•  Choledochoscope•  T-tubeplacement•  Closecholedochotomy


CasePresentaHon

•  Post-operaHvecourse– UrinaryretenHon– Delirium– BileductevaluaHon– DischargedhomePOD#11


QuesHons?www.downstatesurgery.org

SurgicalManagementofCholedocholithiasis


Outline

•  Gallstones•  Gallstonesyndromes•  Choledocholithiasis•  Sequelaeofcholedocholithiasis•  DiagnosHcimaging•  TreatmentopHons•  Refractorystones


Gallstones

•  Cholesterolstones– >70%cholesterol+calcium+bilepigments

•  Blackstones– Small,briRlestones– HemolyHcdisorders

•  Brownstones– BacterialinfecHons–EColibeta-glucuronidase


Gallstones

•  Riskfactors– Female– FerHle– Obesity– Diet– Diseasestates

•  s/pterminalileumresecHon•  s/pgastricresecHon•  Crohn’sdisease•  Pregnancy


GallstoneSyndromes

•  AsymptomaHccholelithiasis

•  Biliarycolic•  AcutecholecysHHs•  Choledocholithiasis•  GallstonepancreaHHs

•  AscendingCholangiHs


AsymptomaHcCholelithiasis

•  IncidentallyfoundgallstonesWITHOUTsymptoms

•  11-36%generalpopulaHon•  3%goontohavesymptomsannually•  NosurgicalindicaHon


BiliaryColic

•  AKAchroniccholecysHHs•  PresentaHon–episodicpost-prandialRUQpain•  DuetotransientcysHcductobstrucHon•  Gallbladdercanappearnormal,inflamedorcontracted/fibrosed

•  Dxtests– US,CTscan– Normallabs

•  Tx–cholecystectomy


AcuteCholecysHHs•  DuetopersistentcysHc

ductobstrucHnggallstones,sludge,orstricture,mass

•  CanleadtoischemicornecroHcgallbladder

•  PresentaHon–persistentRUQpain,N/V,SIRS,elevatedLFT’s

•  Dxtests–US,HIDAscan,CT

•  Tx–anHbioHcs,hydraHon,cholecystectomy


Choledocholithiasis

•  Gallstoneincommonbileduct– Primarystones–brown

– Secondarystones–cholesterol>black

– Retainedstones–immediately

– Recurrentstones


Choledocholithiasis

•  6-12%paHentswithcholelithiasishavecholedocholithiasisaswell

•  20-25%paHents>60yowithsymptomaHcgallstonedisease

•  PresentaHon–transientorpersistentRUQpain,N/V,SIRS,jaundice

•  Labs–elevatedtotalbilirubin,LFT’s,leukocytosis


SequelaeofCholedocholithiasis

•  GallstonepancreaHHs

•  AscendingcholangiHs





•  PancreaHcductobstrucHon•  PresentaHon–epigastricpainradiaHngtotheback/scapula,hyperamylasemia

•  Tx–cholecystectomy,ERCP





•  BilestasiswithbacterialinfecHon

•  Charcot’striad–RUQpain,fever,jaundice

•  Reynold’spentad–Charcot’striad+leukocytosisandAMS

•  Tx–ERCP,cholecystectomy,PTC


EvaluaHonofCholedocholithiasis•  RUQUS•  EUS•  PercutaneoustranshepaHccholangiography

•  HIDAscan•  MRCP•  ERCP•  Intra-operaHvecholangiogram




•  Operator-dependent

•  90%sensiHveforstones

•  DilaHonofCBD>8mm




•  Operator-dependent

•  92-100%sensiHve•  PeriampullaryandpancreaHctumors

•  Biopsy




•  Riskofbleeding,cholangiHs,bileleak




•  Tc99clearedbykupffercellsofliveràbile

•  Normal–fillingofgallbladderandCBDthenduodenumat60minutes








•  Goldstandardfordiagnosis

•  99%successful•  TherapeuHc–stent,sphincterotomy

•  Risks–pancreaHHs,cholagniHs,duodenalperforaHon,bleeding


ERCP

•  Cannulatepapilla•  ContrastinjecHontoevaluatethebiliarytree

•  IntervenHons– Sphincterotomy– Removalofgallstones– Biopsy/brushings– Stentplacement




•  IndicaHons–abnormalLFT’s,pancreaHHs,jaundice,dilatedCBD,failedpre-opERCP

•  Risks–bleeding,CBDinjury,pancreaHHs,infecHon


TreatmentofCholedocholithiasis

•  ObjecHves– RemoveCBDobstrucHon– Removegallbladder



CBDstone RemovalofCBDstone

Removalofgallbladder

ERCP LaparoscopicCholecystectomy

RemovalofCBDstone







RemovalofCBDstone

RemovalofgallbladderIOC






RemovalofCBDstone

RemovalofgallbladderCommonbileductexploraHon

Lithotripsy

DissoluHonDrainageProcedure





PercutaneousCholecystostomy



•  Lithotripsy•  DissoluHon•  CommonbileductexploraHon

•  Drainageprocedure

THESTONEISSTUCK





•  ESWL–soundwaves,uncommonlyused

•  Intra-corporeallaser64-97%effecHve

•  Electrohydrauliclithotripsy





•  ursodeoxycholicacid– decreasescholesterolsaturaHonandgallbladderfuncHon

– 70%effecHve•  methyltert-buthyletherMBTE






CommonBileDuctExploraHon•  LaparoscopictranscysHc–  <6mmstones–  LargecysHcduct>4mm–  CBD<6mm–  Distalstone

•  Laparoscopictransductal–  >6mmstones–  SmallcysHcduct<4mm–  DilatedCBD–  Proximalstone

•  Open


CommonBileDuctExploraHon

•  T-tube– Longitudinalcut– Shortestroutetoskin

– Cholangiogramaper1-2weeks

– Removein2weeksifnostones

– Removein4-6weeksif+stones


•  T-tubeversusprimaryCBDclosure

•  Endpoints–  PosiHvebileculture–  Bloodculture– DuraHonoftachycardia– DuraHonofpost-operaHvefever


•  Conclusion– PrimaryclosuremaybesuperiortoT-tubeplacement

•  CriHcisms– Smallsamplesize– Fewendpoints





•  Transduodenalsphincteroplasty

•  Choledochoduodenostomy•  Choledochojejunostomy


TransduodenalSphincteroplasty

•  IndicaHons– PersistentCBDobstrucHoninNON-dilatedCBD

•  Duodenotomyàcannulateampullaàsphincterotomyat11o’clockàdilatorintoCBDàclosurewithdrain


Choledochoduodenostomy

•  IndicaHons– PersistentCBDobstrucHonindilatedCBD>1.2cm

•  Kocheràcholedochotomyàlongitudinalduodenotomyàside-to-sideanastomosisàdrain


Choledochojejunostomy

•  IndicaHons– PalliaHve– CBDstricture

•  45cmroux-en-Ylimbend-to-sideanastomosis


Summary

•  Bewareofcholedocholithiasis•  VarietyofdiagnosHctools–invasiveandnon-invasive

•  VarietyoftreatmentopHons-invasiveandnon-invasive


QuesHonsWhichofthefollowingregardingthemanagementofcholedocholithiasisisTRUE?A.  ERCPisassociatedwithhighermorbiditythan

laparoscopicCBDexploraHon.B.  StoneimpacHon,periampullarydiverHcula,andMirizzi

syndromeincreasethepossibilityoffailureofERCP.C.  Predictorsofsuccessfulstoneclearanceincludeproximal

stones,largestones,andnumerousstones.D.  LaparoscopicCBDexploraHonislesseffecHveinclearing

commonbileductstonesthanERCP.E.  SurgicalcommonbileductexploraHonrequiresplacement

ofaT-tube.


QuesHonsWhichofthefollowingregardingthemanagementofcholedocholithiasisisTRUE?A.  ERCPisassociatedwithhighermorbiditythan

laparoscopicCBDexploraHon.B.  StoneimpacHon,periampullarydiverHcula,andMirizzi

syndromeincreasethepossibilityoffailureofERCP.C.  Predictorsofsuccessfulstoneclearanceincludeproximal

stones,largestones,andnumerousstones.D.  LaparoscopicCBDexploraHonislesseffecHveinclearing

commonbileductstonesthanERCP.E.  SurgicalcommonbileductexploraHonrequiresplacement

ofaT-tube.


QuesHons26yofemalepresentstotheEDwithRUQabdominalpainx12hours.Onexam,sheisafebrile,anicteric,andhasmildRUQtenderness,negaHveMurphy’ssign.LabsaresignificantforWBC7,AST/ALT28/32,AP331andtotalbilirubin3.2.RUQUSiscompletelynormal.WhichtestisthemostsensiHveandleastinvasivefordiagnosingcholedocholithiasis?A.  HIDAscanB.  CTscanC.  MRCPD.  ERCPE.  EndoscopicUS


QuesHons26yofemalepresentstotheEDwithRUQabdominalpainx12hours.Onexam,sheisafebrile,anicteric,andhasmildRUQtenderness,negaHveMurphy’ssign.LabsaresignificantforWBC7,AST/ALT28/32,AP331andtotalbilirubin3.2.RUQUSiscompletelynormal.WhichtestisthemostsensiHveandleastinvasivefordiagnosingcholedocholithiasis?A.  HIDAscanB.  CTscanC.  MRCPD.  ERCPE.  EndoscopicUS


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Surgical Management of Choledocholithiasis Management... · 2016-11-10 · Quesons Which of the following regarding the management of choledocholithiasis is TRUE? A. ERCP is associated

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