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Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR

Management of Concomitant Gallbladder and Common Bile Duct Stones Joint Hospital Surgical Grand Round 19th October 2013. Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR. Background. 10-18% of patients with gallbladder stones harbor common bile duct stones

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Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR

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  1. Management of Concomitant Gallbladder and Common Bile Duct StonesJoint Hospital Surgical Grand Round19th October 2013 Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR

  2. Background • 10-18% of patients with gallbladder stones harbor common bile duct stones • Before development of laparoscopy • Pre-operative endoscopic retrograde cholangiopancreatography (ERCP) with open cholecystectomy • Open cholecystectomy with exploration of common bile duct • Open cholecystectomy with post-operative ERCP

  3. With advancement in laparoscopic surgery • Laparoscopic cholecystectomy (LC) + CBD exploration (LCBDE) • LC + Intra-operative ERCP • LC + Open cholecystectomy • Pre-operative ERCP + LC • LC + Post-operative ERCP

  4. Factors affecting choice • Patient’s general condition • Previous operation • Stone’s characteristics (size, number, location) • Anatomy of biliary tree • Timing of discovery of CBD stones • Facilities • Expertise in laparoscopic surgery / ERCP

  5. Pre-operative ERCP + LC • Patient presenting with obstructive jaundice / cholangitis / severe pancreatitis • ERCP  initial therapeutic procedure • Followed by lap. cholecystectomy after condition improved • Advantage • Technical skill not demanding • Minimizes operation time • Disadvantage • Two-stage procedure • Possible septic complications between two procedures

  6. LC + Laparoscopic CBD exploration (LCBDE) • Failed endoscopic removal of CBD stones • CBD stones difficult for endoscopic removal • History of gastrectomy • Multiple CBD stones • Large CBD stones • Advantage: • Single-stage procedure • Disadvantage: • Technically demanding • Risks of bile duct complications

  7. LCBDE (Transcystic approach) • Cystic duct is dilated • Balloon / flexible basket / choledochoscope through cystic duct to CBD for stone retrieval • Cystic duct closed with clips / sutures • Contraindications • Biliary stones proximal to cystic duct junction • Small cystic duct • Spiral shape of cystic duct • Large stones • Multiple stones

  8. LCBDE (Choledochotomy) • Longitudinal incision at anterior surface of CBD • Instruments inserted directly CBD to extract stones • Electrohydraulic / Laser lithotripsy • Closure of CBD with sutures +/- placement of T-tube • Indications • Large stones • Multiple stones • Ductal stones proximal to cystic duct junction • Disadvantage • Technically demanding • Risk of bile duct stricture and bile leak • Contraindications • CBD not dilated

  9. On-table ERCP • Rendezvous technique • Guidewire inserted through cystic duct into duodenum • Guidewire caught by duodenoscope • Papillotome inserted over guidewire to facilitate CBD cannulation • Advantage: • Single-stage procedure • 100% cannulation rate • Disadvantage: • Supine positioning may cause ERCP more difficult • Longer operation time • Stones may not be able to clear in one go • Requires ERCP endoscopist / staff / equipments in operating theatre

  10. Post-operative ERCP • CBD stones noted intra-operatively • Non dilated CBD • No expertise in LCBDE • Advantage • Technically not demanding • Disadvantage • Two-stage procedure • Need another operation (CBD exploration) in case of failure • Increased hospital stay and cost

  11. Current Evidence

  12. Pre-op ERCP + LC vs LC + LCBDE • 112 patients with radiological / biochemical evidence of possible CBD stones Rogers SJ et al. Arch Surg 2010; 145(1):28-33. (US)

  13. Pre-op ERCP + LC vs LC + LCBDE • 30 patients with GB stones and CBD stones confirmed on EUS / MRCP Bansal VK et al. Surg Endosc 2010; 24: 1986-1989. (India)

  14. Pre-op ERCP + LC vs LC + on-table ERCP • 91 patients with GB and CBD stones diagnosed by MRCP Morino M et al. Ann Surg 2006; 244: 889-893. (Italy)

  15. Pre-op ERCP + LC vs LC + on-table ERCP Rabago LR et al. Endoscopy 2006; 38: 779-786. (Spain)

  16. LC + LCBDE vs post-op ERCP • 80 patients noted to have CBD stones in operative cholangiogram during lap. cholecystectomy Rhodes et al. Lancet 1998; 351: 159-161. (UK)

  17. LC + LCBDE vs post-op ERCP • 372 patients undergoing LC for symptomatic gallstones noted to have CBD stones by transcystic cholangiography • 286 patients achieved CBD clearance with transcystic approach • Remaining 86 patients in which transcystic clearance was failed Nathanson LK et al. Ann Surg 2005; 242: 188-192. (Australia)

  18. Conclusion • Comparable stone clearance rate and morbidity between all options • Single-stage procedures • Potential benefit of reducing hospital stay / cost • Technically demanding • Depends on patient conditions, stone characteristics, facilities and expertise

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