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“ More Than You Bargained For ”. Dr Asif Khan. Case 1. 38 y/o female. Rt upper quadrant pain and vomiting, deranged LFT’s (obstructive picture) PMH includes ERCP Two stones 8 and 10mm identified but unable to remove, stent was placed and sphincterotomy performed.

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More than you bargained for

More Than You Bargained For”

Dr Asif Khan

Case 1
Case 1

38 y/o female.

Rt upper quadrant pain and vomiting, deranged LFT’s (obstructive picture) PMH includes


Two stones 8 and 10mm identified but unable to remove, stent was placed and sphincterotomy performed.

Laparoscopic Cholecystectomy

MRCP 2007

Clinical exam
Clinical Exam

Afebrile, hemodynamically stable.

Scleral icterus.

Abdomen soft, mildly tender , negative Murphy’s sign.

No rebound tenderness/guarding, no masses appreciated.

Blood Results:

WBC 4.6 x 109/L (4-10 109/L )

AST 258 IU/L (14-54 ) ; ALT 352 IU/L (14-54)

Billirubin 77 umol/L (3.4-20.5)

Alkaline phosphatase 258 IU/L ( 42-121)

INR 1.1


U/S – Dilated CBD (14mm) containing two stones, one 13 mm.

ERCP attempted

Blocked stent , dilated CBD , two large stones >1cm in size, small stones and sludge. Stent changed and surgical intervention suggested as stones unretrievable via ERCP

MRCP – planning – pre IR

Confirms ductal stones and dilated ducts

Prominent ducts especially those beyond the stones in the right radicular duct system.

Modified Burhenne PTC technique - feasible


MRCP; to assess interventional approach

Percutaneous approach
Percutaneous Approach

Right PTC: Access ducts beyond incarcerated stone -a pre-requisite



PTC and cannulation guide wire technique

Modified “ Burhenne” technique

Over the wire Fogarty Balloon - push

Stones were pushed into the duodenum and stent inserted. CBD was cleared.

Post procedure
Post Procedure

Post interventional radiology,

Patient made good recovery

Discharged home no further episodes.

LFT’s normal.

Case 2
Case 2

72 y/o female.

Admitted with RUQ pain , fever and jaundice.

Clinical picture of Cholangitis treated with IV antibiotics ,fluid resuscitation and analgesia.

Recurrent admission for symptomatic choledocholithiasis and repeated ERCP attempts

ERCP 1 -failed

ERCP 2 -failed

ERCP 3 -failed


US Abdomen –Multiple gall stones and CBD diameter 1.1 cm.

MRCP - Gall stones and multiple ductal stones , dilated CBD.

ERCP - Unable to remove stones and stent was inserted.


Open cholecystectomy and CBD Exploration


Findings: More than 12 big and small stones removed from CBD. Normal anatomy.

Duct clear on choledochoscopy.

T tube cholangiogram Day 7 post op

Findings: Two retained stones in Rt duct system.


  • Percutaneous approach to stone clearance

  • Modified “Burhenne technique” – push.

  • T –tube track.

  • Duct cannulation per T tube track. Catheter –wire contrast technique

  • Over the wire Fogarty Balloon stone pull - push to duodenum.


Overnight external drain

Check cholangiogram following morning.

Findings: Duct clear. External drain removal

LFT’S normal.


  • Last 30 years have seen major advances in the management of gallstone disease, which in the U.S. alone, costs over 6 billion dollars per annum to treat.

  • In patients who have cholecystectomy for gallbladder stones, approximately 10% to 18% also have common bile duct (CBD) stones.

Gut 2008;57:1004–1021.doi:10.1136/gut.2007.121657


  • CBD Stones

  • Primary CBD stones

    • Bilirubin is dominant component.

  • Secondary CBD Stones

    • Descend from the gallbladder

    • Cholesterol is dominant component.

    • Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 page

Clinical presentation
Clinical Presentation

  • Asymptomatic

  • Symptomatic

    • Biliary colic with pale stools, dark-colored urine and pruritis.

    • Cholangitis or gallstone pancreatitis.

    • Acute obstructive cholangitis is a life-threatening complication caused by an infection secondary to biliary obstruction.

    • Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages doi:10.1155/2009/840208


Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages

Management options cbd stones
Management Options– CBD Stones

Open cholecystectomy + CBD exploration.

ERCP + Endoscopic Sphincterotomy (followed by cholecystectomy – most frequently used).

Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in specialized centers.

Choledochoscopy at laparoscopy or percutaneous choleydochoscopy or choleydochoscopy through T tube.

Cbd stones
CBD stones

  • ERCP has become a popular technique to clear CBD stones.

  • Currently in the laparoscopic era studies have shown that laparoscopic treatment of CBD stones is possible and is potentially as effective as ERCP.

  • This is most commonly done by a transcystic approach, though evidence of success in large volume cohorts with a more technically demanding laparoscopic Choledochotomy is emerging .

    (Fletcher 1994 ;Cuschieri 1996; Lezoche 1996)


  • Despite the fact that therapeutic ERCP is increasingly being used to manage biliary tract diseases, the procedure remains compounded by two persistent problems: failure of successful biliary cannulation, and post ERCP-pancreatitis (PEP).

  • PTC and guide-wire cannulation has been proposed as a simple way to avoid PEP.

    Lella F, Bagnolo F, Colombo E, Bonassi U. A simple way of avoiding post- ERCP pancreatitis. Gastrointest Endosc 2004; 59: 830-834.

    Bailey AA, Bourke MJ, Williams SJ, et al. A prospective randomized trial of cannulation technique in ERCP: Effects on technical success and post-ERCP pancreatitis. Endoscopy 2008; 40: 296-301.

Management cbd stones
Management – CBD Stones

  • Burhenne technique

    • Treatment of retained CBD stones found on T tube cholangiography

    • Technique modified by ERCP and sphincterotomy practice

      • Percutaneous extraction or duodenal deposition under fluoroscopic control. Catheter –wire – contrast - balloon

      • Approach depends on ? +/- sphincterotomy

      • Percutaneous sphincteroplasty - alternative

        British Journal of SurgeryVolume 78 Issue 8, Pages 959 - 960

        Vanderburgh L, Yeung EY, Ho CS. Radiologic management of problematic biliary calculi. Sem Intervent Radiol1986; 13:69 –77

Management cbd stones1
Management – CBD Stones

  • Percutaneous therapy is the option before resorting to surgery.

  • Fluoroscopically-guided extraction of resident calculi through a sinus tract T tube (Kher tube) is a well-established procedure.

  • If no T tube is in place, a transhepatic approach may be attempted.

  • “Rendez-vous”technique. Combined percutaneous IR and endoscopic ERCPprocedure

    Burhenne HJ. Percutaneous extraction of retained biliary tract stones: 661 patients. AJR1980

Rendez vous guide wire technique
Rendez-vous guide-wire technique

  • The PTC guide-wire technique seems to reduce the incidence of post-ERCP pancreatitis in the elderly as compared to the conventional contrast technique, but does not appear to improve the primary success rate for biliary cannulation during ERCP in this population.

    Lazaraki G, Katsinelos P. Prevention of post- ERCP pancreatitis: an overview. Ann Gastroenterol 2008; 21: 27-38.

Adjuvant techniques with ercp es
Adjuvant Techniques with ERCP+ES

Laparoscopic CBD exploration/Choleydochoscopy.

Mechanical lithotripsy

LASER lithotripsy

Electrohydraulic lithotripsy


Chemical contact dissolution therapy

Take home message
Take Home Message

  • CBD Stones associated with 10-18 % of patients

    undergoing cholecystectomy.

  • Advanced endoscopic & laparoscopic

    techniques have revolutionized management.

  • PTC and IR (guide wire cannulation) are still successful techniques for retained stones.