slide1 n.
Download
Skip this Video
Loading SlideShow in 5 Seconds..
Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR PowerPoint Presentation
Download Presentation
Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR

Loading in 2 Seconds...

play fullscreen
1 / 18

Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR - PowerPoint PPT Presentation


  • 148 Views
  • Uploaded on

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

loader
I am the owner, or an agent authorized to act on behalf of the owner, of the copyrighted work described.
capcha
Download Presentation

PowerPoint Slideshow about 'Dr. Wong Chun Lam Pamela Youde Nethersole Eastern Hospital Hong Kong SAR' - hyatt-jensen


An Image/Link below is provided (as is) to download presentation

Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author.While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server.


- - - - - - - - - - - - - - - - - - - - - - - - - - E N D - - - - - - - - - - - - - - - - - - - - - - - - - -
Presentation Transcript
slide1

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

background
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
with advancement in laparoscopic surgery
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
factors affecting choice
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
pre operative ercp lc
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
lc laparoscopic cbd exploration lcbde
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
lcbde transcystic approach
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
lcbde choledochotomy
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
on table ercp
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
post operative ercp
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
pre op ercp lc vs lc lcbde
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)

slide13

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)

pre op ercp lc vs lc on table ercp
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)

pre op ercp lc vs lc on table ercp1
Pre-op ERCP + LC vs LC + on-table ERCP

Rabago LR et al. Endoscopy 2006; 38: 779-786. (Spain)

lc lcbde vs post op ercp
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)

lc lcbde vs post op ercp1
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)

conclusion
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