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A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS. BY: Jonathan R. Malabanan, M.D. Ospital ng Maynila Medical Center Department of Surgery. General Data: A.M. 35 –years- old Female Binondo, Manila.

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slide1
A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

BY:

Jonathan R. Malabanan, M.D.

Ospital ng Maynila Medical Center

Department of Surgery

slide2

General Data:

A.M.

35 –years- old

Female

Binondo, Manila

slide3

Chief Complaint:

Yellowish discoloration of the eyes

history of present illness
HISTORY OF PRESENT ILLNESS

One month PTC=

=RUQ pain, colicky, moderate to severe, radiating to R scapular area

=no fever, no yellowish discoloration of skin and sclerae

=no consult, no meds

history of present illness1
HISTORY OF PRESENT ILLNESS

One week PTC =persistence of colicky right upper quadrant pain

=yellowish discoloration of skin and sclerae

=(+) light colored stool

=(+) consult, HBT- UTZ done: Choledocholithiasis, Cholecystolithiais

Advised OR, and was scheduled for operation

past medical history
Past Medical History
  • No hypertension
  • No diabetes
  • No PTB
  • No previous hospitalization
  • No allergies to foods and drugs
family history
Family History
  • unremarkable
personal and social history
Personal and Social History
  • Unremarkable
  • Occasional alcoholic beverage drinker
physical examination
Physical Examination
  • General Survey:
    • Conscious, coherent, not in respiratory distress
  • Vital Signs

BP = 110/ 60 mmHg CR = 81 bpm

RR = 20 cpm Temp: 37 degrees Celsius

physical examination1
Physical Examination
  • Skin: yellowish coloration of skin
  • HEENT:

-Pink palpebral conjuctivae, icteric sclerae, no CLAD, no TPC, no NAD, supple neck.

  • Chest:
    • Symmetrical chest expansion, no retractions,
    • CBS
physical examination2
Physical Examination
  • Heart

normal rate, regular rhythm, no murmur

  • Abdomen

Flat, NABS, soft, with Direct Tenderness RUQ, no organomegaly.

physical examination3
Physical Examination
  • Extremities:
    • Full and equal pulses, no deformities, no cyanosis

DRE:

-light colored stool

salient features
Salient Features
  • 1.35/Female
  • 2. RUQ pain
  • 3. Yellowish discoloration of the eyes, skin
  • 4. Light colored stool
  • 5. UTZ result of Hepatobiliary Tree: dilated CBD, normal liver, portal vein and tributaries are unremarkable, intrahepatic ducts not dilated, with an intraluminal echogenic focus exibiting acoustic shadowing
slide14

NON OBSTRUCTIVE

OBSTRUCTIVE

JAUNDICE

INTRAHEPATIC

EXTRAHEPATIC

INTRADUCTAL

COMPRESSION OF BILIARY TRACTS

HEMOLYSIS

HEPATOCELLULAR

slide15

OBSTRUCTIVE

EXTRAHEPATIC

INTRAHEPATIC

GB/CBD stones

Pancreatic Ca

Primary Biliary Cirrhosis

Sclerosing Cholangitis

Pattern Recognition (90-95%)

RUQ pain

Clinical Jaundice

CBD dilatation

para clinical diagnostic procedure
Para clinical Diagnostic Procedure
  • Do I need to perform a Para clinical diagnostic procedure?

“No”

pre treatment diagnosis
Pre Treatment Diagnosis

Obstructive Jaundice prob secondary to

Choledocholithiasis

Cholecystolithiasis

goals of treatment
GOALS OF TREATMENT
  • Resolution of obstruction
  • Prevention of complication
treatment options
Treatment Options

Meta-analysis ofendoscopy and surgery versus surgery alone

for common bile duct stones with the gallbladder in situ, Clayton et.al. University of Athens 2006

management
Management
  • OPEN CBDE
  • CHOLECYSTECTOMY, IOC
preoperative preparation
Preoperative Preparation
  • Informed consent
  • Provide psychosocial support
  • Optimize patient’s condition
  • NPO for 6 hours
  • Preparation of OR materials
operative technique
Operative technique
  • Patient supine under GA
  • Asepsis/Anti-sepsis
  • Sterile drapes placed
  • Right paramedian incision carried down from skin to subcutaneous tissue, fascia and peritoneum entered
  • Intraoperative findings noted
operative technique1
Operative Technique
  • Cystic artery identified, ligated and cut
  • Cystic duct identified, isolated and tagged
  • Gallbladder removed. Intraoperative findings noted.
  • French 5 feeding tube inserted into the cystic duct, IOC done, results noted
  • CBD opened logitudinally and explored
operative technique2
Operative Technique
  • T-tube inserted and anchored
  • Hemostasis
  • Correct sponge and instruments count
  • Layer by layer closure
  • DSD
operative findings
Operative Findings
  • Intraoperative findings noted
    • GB is distended with thickened walls measuring 10x4cm; on opening up, it contained multiple stone measuring 0.2-0.3cm, cystic duct measures 0.5cm in diameter; CBD measured 12mm in diameter; on IOC, there was a filling defect on the distal CBD, there was visualization of both intrahepatic ducts. On CBDE, 8mm primary stone was noted at the distal common bile duct. Pancreas was normal. Liver was noted to be cirrhotic.
postoperative diagnosis

Postoperative Diagnosis

Obstructive Jaundice Secondary to Choledocholithiasis

Cholelithiasis

Operation Done

Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy

postoperative management
Postoperative Management
  • Adequate analgesia
  • Monitoring of VS and hydration.
  • DAT
  • Adequate monitoring: complications
  • Patient was discharged on the 5th post operative day
  • Follow up after a week.
final diagnosis
Final Diagnosis
  • Obstructive Jaundice Secondary to Choledocholithiasis
  • Cholelithiasis
  • S/P Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy
course in the ward
COURSE IN THE WARD
  • 1st Hospital Day
    • NPO
    • Adequate Antibiotic
    • Adequate Analgesia
    • DWC
course in the ward1
COURSE IN THE WARD
  • 2nd-3rd Hospital Day
    • GL- Soft diet
    • Adequate Antibiotic
    • Adequate Analgesia
    • DWC
course in the ward2
COURSE IN THE WARD
  • 4th Hospital Day
    • DAT
    • Adequate Antibiotic
    • Adequate Analgesia
    • DWC
course in the ward3
COURSE IN THE WARD
  • 5th Hospital Day
    • Patient discharged
prevention and health promotion
PREVENTION AND HEALTH PROMOTION
  • Advise given to patient regarding
    • Possible complications
    • Proper wound care
  • OPD follow up after 7 days for removal of sutures
  • Anticipate complications
    • Avoid Recurrence
    • Avoid infection
common bile duct stones
Common Bile Duct Stones
  • 10% of patients who present for Cholecystectomy
  • definitive treatment is cholecystectomy and ductal clearance either through open CBDE, Lap CBDE, ERCP.
  • Manuevers include administration of glucagon and flushing of ductal system,dilatation of the distal CBD, balloon catheter, basket extraction.
overview to patient management
Overview to Patient Management
  • CBD stones can be discovered preoperatively, intraop, post-op.
  • Treatment options:
    • ERCP=/-S
    • Lap CBDE
    • Lap Chole + ERCP
    • Open CBDE
    • almost same success rate
completion cbde
Completion CBDE
  • T tube placement:
    • decompression of the duct, incase of residual obstruction
    • access for ductal imaging postop
    • access for removal of stone
    • left as early as 4 days up to 6 weeks
    • complicatios: bile leaks, peritonitis
slide40
Post Cholecystectomy CBDE Problems
  • Early Problems
    • bile duct injury: laceration, cystic duct stump leak, liver bed leak
    • bile duct obstruction: retained stone
    • biliary pancreatitis
  • Late Problems
    • stricture
    • postcholecystectomy syndrome
    • GERD
questions
Questions

#1 (MCQ) Which of the following is the main chemical component of pigment stones? A. CholesterolB. Calcium bilirubinate C. Calcium carbonateD. Calcium phosphate

E: Calcium oxalate

questions1
Questions

#2 (MCQ) What is the most commonly isolated bacteria in the common duct of patient with primary stone?

A. Escherichia coli

B. Pseudomonas aeruginosa

C. Klebsiella sp.

D. Salmonella typhii

E. Corynebacterium sp.

questions2
Questions

#3 (MCQ) Which of the following is the best indication for preoperative ERCP in patients with gallstones?

A. Gallstone pancreatitis

B. Obstructive jaundice

C. History of jaundice

D. Increased alkaline phosphatase to twice normal

E. 1.6 cm common bile duct dilatation

questions3
Questions

(MCR)

Direction: Write

“A” if 1, 2, and 3 are valid statements.

“B” if only 1 and 3 are valid statements.

“C” if only 2 and 4 are valid statements.

“D” if only 4 is a valid statement.

“E” if all are valid statements.

questions4
Questions

#4 (MCR)

The following are drainage procedure after open/laparoscopic CBDE.

1. Sphincteroplasty

2. Choledochojeunostomy

3. Choledochoduodenostomy

4. Choledochotomy

questions5
Questions

#5 (MCR)

Correct statement about biliary scintigraphy using technetium 99m- labeled derivatives of iminoacetic acid (HIDA) include:

questions6
Questions

#5 (MCR)

1. Nonvisualization of GB is strong evidence of cystic duct obstruction.

2. The isotope is cleared by Kupffer’s cells

3. The GB in a fasting subject is normally visualized within 60 minutes of the dye injection

4. The scan is the preferred initial step in identifying common duct stones

journal appraisal
Journal Appraisal
  • Evaluation of primary duct closure vs T-tube drainage following choledochotomy

Marwah Sanjay, Singh Ishwar, Godara Rajesh, Sen Jyotsana, Marwah Nisha, Karwasra RKDepartments of Surgery, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, IndiaYear : 2004  |  Volume : 23  |  Issue : 6  |  Page : 227-228

objective
Objective
  • To assess the benefits and harms of primary closure versus routine T-tube drainage in open common bile duct exploration for common bile duct stones.
design
Design:
  • Randomized Control Trial
patients
Patients:
  • Forty consecutive patients undergoing elective minilap cholecystectomy and CBD exploration for gallstones with CBD stones (proved preoperatively on ultrasonography) were studied prospectively.
intervention
Intervention:
  • Patients were randomly divided in two groups: Group A underwent primary closure of CBD, group B had T-tube drainage after CBD exploration.
main outcome measures
Main outcome measures:
  • The duration of hospital stay, mortalities, morbidities and outcome.
conclusion
Conclusion
  • The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality.
clinical question
Clinical Question
  • In cases of obstructive jaundice secondary to choledocholithiasis, is mandatory t- tube choledochostomy necessary?
tentative answer
Tentative Answer
  • No
    • mandatory t tube choledochosyomy is not necessary for cases of obstructive jaundice secondary to choledocholithiasis.
are the results of the study valid
Are the results of the study valid?

Primary Guides:

1. Was the assignment of patients to treatment randomized?

Yes.

are the results of the study valid1
Are the results of the study valid?

Primary Guides:

2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?

Yes.

are the results of the study valid2
Are the results of the study valid?

Secondary Guides:

Were patients, their clinicians, and study personnel "blind" to treatment?

No.

are the results of the study valid3
Are the results of the study valid?

Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

Yes.

are the results of the study valid4
Are the results of the study valid?

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.

are the results of the study valid5
Are the results of the study valid?

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.

conclusion1
Conclusion
  • The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality.
  • Primary closure of CBD is more safe and physiological and the procedure of choice following routine choledochotomy.
references
References
  • Schwartz et. al Principles of Surgery.8th ed. Chapter 6.
  • Marwah S, Singh I,Godara R, Sen J,MarwahN, Karwasra RK. Evaluation of primary duct closure vs T-tube drainage following choledochotomy.

Indian Journal of Gastroenterology 2004;23(6):227–8.

  • Wright BE, Freeman ML, Cummings JK et. al.: Current Management of Common Bile Duct Stones. Surgery. 132:729-735, 2002.
slide72

EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON COMMON BILE DUCT STONES FOR SURGICAL PROCEDURES:

UPDATE 2004

common bile duct stones1
COMMON BILE DUCT STONES
  • 1. What is the recommended ancillary procedure in a patient with suspected

common duct stone to confirm its diagnosis?

slide74

Magnetic resonance cholangiography is the recommended procedure for patients with suspected common bile duct stones to confirm the diagnosis.

slide75

2. What is the recommended treatment for patients with CBD stones without

cholangitis?

  • The recommended treatment for patient with CBD stones without cholangitis is

surgical treatment.

slide76

3. Among the different treatment options for common bile duct stones, which

procedure has the least recurrence?

  • Choledochoduodenostomy has the least recurrence.
slide77

4. What is the recommended treatment for patients with gall bladder stones after

endoscopic common bile duct clearance?

  • The recommended treatment for patients with gall bladder stones after endoscopic

common bile duct clearance is surgery, to be performed within 24 to 48 hours after

clearance.

intrahepatic stones hepatolithiasis
INTRAHEPATIC STONES (HEPATOLITHIASIS)
  • 1. What is the recommended diagnostic tool to confirm the presence of intrahepatic

stones with or without strictures?

slide79

Magnetic resonance cholangiography is the recommended diagnostic tool to confirm the presence of intrahepatic stones.

slide80

2. What is the recommended treatment for intrahepatic stones with or without

strictures?

  • The recommended treatment include surgical management (hepatic resection) and cholangioscopic techniques, whether through a T-tube tract, a percutaneous transhepatic approach (PTBD/PTCS) or a transpapillary approach, singly or in combination.
cholangitis
CHOLANGITIS
  • 1. What is the antibiotic of choice for patients with cholangitis?
  • The recommended antibiotics for the treatment of cholangitis are: Ciprofloxacin 200mgs IV BID or Ceftazidime 1gm IV BID + Ampicillin 500mgs IV QID + Metronidazole 500mgs IV TID
slide82

2. What is the recommended treatment for patients with severe cholangitis?

  • The recommended treatment for patients with severe cholangitis is non-operative biliary drainage (endoscopic).
retained common bile duct stones
RETAINED COMMON BILE DUCT STONES
  • 1. What is the recommended treatment for retained common bile duct stones?
  • For patients who have had prior cholecystectomy and have a high probability of common bile duct stones, ERCP and sphincterotomy with DORMIA basket extraction is the preferred initial approach.
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