CURRENT TRENDS IN

MANAGEMENT OF
CHOLEDOCHOLITHIASIS

S.K. SAHU
MODERATOR –
DR A. SILODIA
INTRODUCTION – CBD stones

 Present in 10 – 15 % of cholecystectomy pts

 Incidence rises with age, duration of

gallstone symptoms

 Associated with high rate of complications

 Should always be removed

CLASSIFICATION – CBD Stones

 By the point of origin

2. Primary CBD Stones
3. Secondary CBD Stones

 By the time of discovery relative to

cholecystectomy
6. Retained
7. Recurrent
PRESENTATION – CBD Stones

 Biliarycolic
 Jaundice
 Pale stools
 Darkening of urine
 Fever with chills – cholangitis
 Charcots triad, Reynolds pentad
LABORATORY INVESTIGATIONS

 Elevated s. bilirubin,aminotransferase,
alkaline phosphatase

 Maybe normal in 1/3 of patients with CBD

Stones
DIAGNOSING CBD STONES

 USG
– decreased sensitivity
– retro and intraduodenal stones not visualized
 EUS
– increased sensitivity
 ERCP
– added advantage of being therapeutic in distal
stones
DIAGNOSING CBD STONES

MRCP
 not a therapeutic procedure
 does not have morbidity and mortality
associated with ERCP
 may avoid use of unnecessary invasive
procedures
Indications of MRCP

 unsuccessful or contraindicated ERCP

 patient preference for non-invasive imaging
 patients considered to be at low risk of
having pancreatic or biliary disease;
 patients where need for therapeutic ERCP is
unlikely
 with a suspected neoplastic cause for
pancreatic or biliary obstruction
CBD Stone on USG
CBD Stone on EUS
CBD Stone on MRCP
CBD Stone on IOC
MANAGEMENT – CBD Stones

 Open cholecystectomy + surgical

exploration of the CBD – in the past/
centres where laparoscopy not available
 ERCP + Endoscopic Sphincterotomy
followed by cholecystectomy – most
frequently used
 Laparoscopic cholecystectomy +
Laparoscopic CBD exploration – in
experienced hands
OPEN CBD EXPLORATION

 Time tested method

 Indicated if
4. Stones detected during open
cholecystectomy
5. Need for biliary enteric anastamosis
6. Endoscopy difficult / risky
7. Unsuccessful LCBDE
8. Impacted/ multiple / larger stones
OPEN CBD EXPLORATION

 Contraindicated in
2. Small CBD <5mm
3. Portal HT
4. Severe periportal inflammation
5. Cholangitis with septic shock
ERCP + ES - Indications

 CBD Stones detected prior to

cholecystectomy

 High risk patients unfit for operation

 Severe cholangitis / pancreatitis

CBD Stone on ERCP
ERCP + ES - complications

 Pancreatitis(7%)
 Cholangitis
 Bleeding (2%)
 Perforation
 Abscess, recurrence
 Duodenobiliary reflux
 Rarely death
ERCP +ES - Limitations

 Operator dependent

 Cost & need for 2nd stage – a concern

 Positive ERCP in only 34 % of cases

ADJUVANT TECHNIQUES with ERCP
+ES

 Mechanical lithotripsy

 LASER lithotripsy

 Electrohydraulic lithotripsy

 ESWL

 Chemical contact dissolution therapy

ADJUVANT TECHNIQUES - indications

 Stones larger than the endoscope

 Shape square/ piston shaped / faceted

 Tightly packed stones/ hard stones

 Intrahepatic stones

 Stones proximal to CBD stricture

Laparoscopic CBD Exploration
(LCBDE)

Components
 Laparoscopic cholecystectomy

 Intraoperative cholangiography

 Exploration if stone detected

LCBDE - Indications

 Abnormal intraoperative cholangiogram or

sonogram

 Scintigraphic/ endoscopic / radiographic

evidence of bile duct stones

 History of biliary pancreatitis

LCBDE - contraindications

 Coagulopathy

 Local porta pathology

 Inability of surgeon to do LCBDE

 Unfit patient
LCBDE - Approach

Transcystic

Choledochotomy
Transcystic LCBDE

 Preferred approach
 Easy, more physiological
 Cystic duct should join CHD laterally or
posteriorly
 Indicated in small (<6mm), limited no of
stones(<5),absence of CHD stones
 Laparoscopic choledochotomy

 Used if cystic duct cant be dilated /

intrahepatic pathology

 Indicatedin large (>6mm), more than 5

stones, CHD stones

 Spiral course of cystic duct/ medial opening

of cystic duct is an indication
LCBDE - advantages

 Single admission/ short hospital stay

 Reduced morbidity/ mortality

 Success rate comparable to ERCP +ES

 FailedLCBDE can be converted to open in

the same sitting
LCBDE - limitations

 Increased operative time / cost

 Expertise not commonly available

 SUSPECTED CBD Stones

jaundice No jaundice

Severe comorbidity Fit for surg MRCP

ERCP+ES Lap chole+IOC STONES present No stones

No further action Stones unfit fit Lap chole

Operative Post op
ERCP Chole +ECBD
removal ERCP

FailureThen Failure then

choledochoduodenostomy Repeat surgery
CONCLUSION

 CBD Stones associated in 10 – 15 % pts

undergoing cholecystectomy
 Advanced endoscopic & laparoscopic
techniques have revolutionised management
 Treatment depends on resources, technical
limitations, surgeons expertise
 LCBDE is safe, feasible, single stage
management option for CBD stones
THANK YOU