Benign Biliary Disease

Gallstone Disease [ Speed]

STONE DISEASE

• 3 types:
  1. Cholesterol = 100% cholesterol = Cholesterol MONOHYDRATE = 15% radio opaque = Hard golden yellow
  2. Mixed = >30% cholesterol = MC in WORLD
  3. Pigment
     1. Black
        1. insoluble bilirubin pigments + Ca PO4 + CaCO3
        2. very hard & >50% radio opaque
        3. Incidence = 10-15%
        4. MC in Children
        5. MC in Hemolytic Anemias
        6. Exclusively seen in GB ( not seen in CBD)
     2. Brown:
        1. [Ca Palmitate; Stearate; Bilirubinate] + <30% Cholesterol
        2. Radioluscent ( 100%)
        3. Soft earthy stones
        4. MC
           1. in Asians
           2. in Infections = Ecoli; Ascaris; CL sinensis; Hepatolithiasis
           3. in Fb & stents
           4. Primary CBD stones [ But MC stone in Bile ducts = Secondary BD stone either mixed/ cholesterol]

Management of Gall stone disease:

Natural History Stone disease

• 80% are asymptomatic
• 20-30% will develop symptoms within 20 years
• Risk of symptoms is 2-3% per year
• Risk of Complications is 1-2% per year before symptom onset

Natural History of Gallstone with Cancer

• Risk of Gall bladder cancer is 1% at 20 years after diagnosis
• Risk of gall bladder cancer is 0.02% per year
• Incidence of GB cancer in population of patients with stones is 0.3 to 3%
• Increased risk of Cancer:

  • 2.5 or 3 cm stones [ size but not number]

  • Choledochal cyst
  • ABPJ
  • Chilean/ North indian
  • PSC
  • Stone with polyp / calcification
  • polyp > 1cm ; in PSC if >6mm

Indications of Prophylactic Cholecystectomy:

Cardiac & lung transplant = do cholecystectomy if the pt has gall stone disease ; and for other transplants = expectant

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ACUTE CHOLECYSTITIS: [SPEED]

Pathogenesis:

• Positive bile cultures are found in approximately 20% of patients with acute cholecystitis,
• the most common of which are gram-negative bacteria of gastrointestinal origin, such as Klebsiella spp. and Escherichia coli.
• The incidence of bactobilia has been reported to be as high as 60% in patients who have had endoscopic sphincterotomy or other biliary instrumentation

TG18/TG13 diagnostic criteria for acute cholecystitis

A. Local signs of inflammation etc.

(1) Murphy's sign, (2) RUQ mass/pain/tenderness

B. Systemic signs of inflammation etc.

(1) Fever, (2) elevated CRP, (3) elevated WBC count

C. Imaging findings

Imaging findings characteristic of acute cholecystitis

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Suspected diagnosis:

one item in A + one item in B

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Definite diagnosis:

one item in A + one item in B + C

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****TG18/TG13 severity grading for acute cholecystitis

Grade III (severe) acute cholecystitis

“Grade III” acute cholecystitis is associated with dysfunction of any one of the following organs/systems:

1. Cardiovascular dysfunction: hypotension requiring treatment with dopamine ≥5 μg/kg per min, or any dose of norepinephrine

2. Neurological dysfunction: decreased level of consciousness

3. Respiratory dysfunction: PaO2/FiO2 ratio <300

4. Renal dysfunction: oliguria, creatinine >2.0 mg/dl

5. Hepatic dysfunction: PT-INR >1.5

6. Hematological dysfunction: platelet count <100,000/mm3

Grade II (moderate) acute cholecystitis

“Grade II” acute cholecystitis is associated with any one of the following conditions:

1. Elevated WBC count (>18,000/mm3)

2. Palpable tender mass in the right upper abdominal quadrant

3. Duration of complaints >72 h ( lap chole performed within 96hrs of onset)

4. Marked local inflammation (gangrenous cholecystitis, pericholecystic abscess, hepatic abscess, biliary peritonitis, emphysematous cholecystitis)

Grade I (mild) acute cholecystitis

“Grade I” acute cholecystitis does not meet the criteria of “Grade III” or “Grade II” acute cholecystitis. It can also be defined as acute cholecystitis in a healthy patient with no organ dysfunction and mild inflammatory changes in the gallbladder, making cholecystectomy a safe and low-risk operative procedure

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Management of Acute Cholecystitis:

• check for severity = mild/ moderate/ severe

• MILD:

  • (lambda) Low risk = CCI ≤ 5 and / or ASA I/II
  • (mu) High Risk = CCI > 5 and / or ASA > II

  

  TG18 flowchart for the management of acute cholecystitis Grade I. λ, CCI 5 or less and/or ASA class II or less (low risk); µ, CCI 6 or greater and/or ASA class III or greater (not low risk); ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. ASA-PS American Society of Anesthesiologists physical status.

• Moderate:

  • Low risk = CCI ≤ 5 and / or ASA I/II = operate urgent/early
  • High Risk = CCI > 5 and / or ASA > II = delayed / elective

  

  TG18 flowchart for the management of acute cholecystitis Grade II. α, antibiotics and general supportive care successful; ϕ, antibiotics and general supportive care fail to control inflammation; λ, CCI 5 or less and/or ASA-PS class II or less (low risk); µ, CCI 6 or greater and/or ASA-PS class III or greater (not low risk); ※, performance of a blood culture should be taken into consideration before initiation of administration of antibiotics; †, a bile culture should be performed during GB drainage; ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. ASA-PS American Society of Anesthesiologists physical status, CCI Charlson comorbidity index, GB gallbladder, LC laparoscopic cholecystectomy.

• Severe:

  • Negative Predictive factors:
    • jaundice (bil ≥ 2)
    • Neurological & Respiratory dysfunction
  • FOSF: Favourable organ system failure
    • CVS or Renal failure which is rapidly reversible after admission and before early LC in AC
  • Low risk: CCI ≤ 3 and / or ASA I/ II ⇒ we can go for Early LC

  

  TG18 flowchart for the management of acute cholecystitis Grade III. ※, performance of a blood culture should be taken into consideration before initiation of administration of antibiotics; #, negative predictive factors: jaundice (TBil ≥2), neurological dysfunction, respiratory dysfunction; Φ, FOSF: favorable organ system failure = cardiovascular or renal organ system failure which is rapidly reversible after admission and before early LC in AC; , in cases of Grade III, CCI (Charlson comorbidity index) 4 or greater, ASA-PS 3 or greater are high risk; †, a bile culture should be performed during GB drainage; Ψ, advanced center = intensive care and advanced laparoscopic techniques are available; ▵, in case of serious operative difficulty, bail-out procedures including conversion should be used. GB gallbladder, LC laparoscopic cholecystectomy, PS* performance status

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Benign Biliary Disease [DT]

History of Gall Bladder Disease

Key Historical Milestones

• Jean-Louis Petit (1743): Performed the first cholecystostomy.
• Carl Langenbuch: A pioneering German surgeon, performed the first cholecystectomy.
• Eric Muhe (1985): Conducted the first laparoscopic cholecystectomy.

Gallstone Disease: Complicated vs. Uncomplicated

• Uncomplicated Disease:
  • Biliary colic
  • Chronic cholecystitis
• Complicated Disease:
  • Acute cholecystitis
  • Obstructive jaundice
  • Gallstone ileus
  • Acute gallstone pancreatitis

MCQ 1

• Answer: c) Chronic cholecystitis
• Explanation: Chronic cholecystitis is classified under uncomplicated gallstone disease, while the others listed are considered complicated diseases.

Biliary Colic and Severe Disease

MCQ 2

• Answer: a) 8-9%
• Explanation: This is the reason for recommending elective cholecystectomy for symptomatic cholelithiasis, to prevent the progression to severe disease.

Asymptomatic Gallstones

• Prophylactic Cholecystectomy: Not recommended as symptoms develop in only 10-30% of cases.
• Complications: Occur in 1-8% of cases.

Risk Factors for Developing Gallstone-Related Events:

• Gender: Female
• Stone Size: Greater than 1 cm
• Number of Stones: Two or more

Indications for Prophylactic Cholecystectomy in the Presence of Gallstones

MCQ 3

• Answer: c) Cardiac transplant
• Explanation:
  • Post-Cardiac Transplant: Elective laparoscopic cholecystectomy is recommended to prevent gallstone-related complications.
  • RYGB (Roux-en-Y Gastric Bypass): A 6-month course of UDCA (Ursodeoxycholic acid) is recommended to reduce the incidence of cholecystectomy (10% in UDCA users vs. 25% in non-UDCA users), but prophylactic cholecystectomy is not generally recommended.
  • Immunotherapy Patients: No significant increase in gallstone disease.
    • Acalculous Cholecystitis Risk: increased in patients who are on Immunosuppresive drugs

References:

• Blumgart 7th Edition; Page 478.

Bactibilia and Acute Cholecystitis

Bactibilia

• Definition: Bile that has been subjected to culture, growing an organism.
• Acute Cholecystitis: 20% positive culture rate.
• Sphincterotomy and Instrumentation: Increases the risk, with a 60% positive culture rate.
  • Reference: Blumgart 7th Edition; Page 478.

Tokyo Guidelines for Acute Cholecystitis

Diagnostic Categories

• Imaging Findings:
  • Pericholecystic fluid
  • GB wall edema ≥ 4mm
  • Luminal debris
  • Stone impaction
  • Sonographic Murphy's sign
• Local Signs of Inflammation:
  • Murphy's Sign or right upper quadrant mass or tenderness.
• Systemic Inflammation Signs:
  • Fever
  • Elevated CRP
  • Elevated WBC

Reference: Blumgart 7th Edition; Page 479.

MCQ 4

• Answer: d) Specificity for mortality - 97%
• Explanation: Overall sensitivity and specificity for the Tokyo Guidelines are 91% and 97%, respectively, but they are not specific for mortality.

Imaging for Gallstone Disease

MCQ 5

• Answer: d) CT is equally sensitive in diagnosing acute cholecystitis
• Explanation: In early cholecystitis, USG is more sensitive than CT.

Risk Factors for Conversion to Open Surgery in Acute Cholecystitis

MCQ 6

• Answer: c) Elevated ALP
• Explanation: Elevated bilirubin, not ALP, is a risk factor for conversion to open surgery.

Subtotal Cholecystectomy

Subtotal Cholecystectomy: Fenestration vs. Reconstituting

Fenestration Subtotal Cholecystectomy

• Complications:
  • Bile leak
  • Wound infection
  • Longer hospitalization
  • Completion cholecystectomy may be required.

Reconstituting Subtotal Cholecystectomy

• Complications:
  • Recurrent biliary pathology
  • ERCP or endoscopic interventions may be required

Re-intervention Rate

• ERCP and Completion Cholecystectomy: The re-intervention rate is the same for both fenestration and reconstituting subtotal cholecystectomy.

Management and Outcomes of Grade III Acute Cholecystitis

MCQ 7

• Answer: d) LASEMS can be placed after cholecystostomy in patients who are not fit for cholecystectomy
• Explanation: The use of LASEMS (Lumen-Apposing Self-Expanding Metallic Stents) is not a standard practice following cholecystostomy in patients who are not fit for cholecystectomy. Instead, it should be placed. before because the gb has to be distended for placement of LASEMS
• LASEMS (Lumen-Apposing Self-Expanding Metallic Stents) : duodenal wall punctured and GB wall is punctured with guidewire and LASEMS is placed which drains the gb into the duodenum which can reduce the need for external drainage and is experimental and has risk of perforation and leak into surrounding tissues with risk of failure being high.

Cholecystostomy Outcomes

• Symptom Improvement: 80% of patients experience improvement in symptoms with cholecystostomy.
• Tube-Related Complications: 33% of patients develop complications related to the drainage tube.
  • bleeding
  • leak
  • peritonitis
• Conversion Rates:
  • Following Cholecystostomy: 14-32% conversion rate from laparoscopic to open surgery.
  • Elective Cholecystectomy: 5% conversion rate.
  • Emergency Cholecystectomy: 6% conversion rate.

Management After Cholecystostomy

• Patients Not Fit for Cholecystectomy:
  • Tube Management [ Removal Vs Destiny Tube]: Decision between removal or maintaining the drainage tube (depends on calculous vs. acalculous cholecystitis).
• Recurrent Cholecystitis:
  • Early Removal of Tube:
    • Less than 44 days is associated with a risk of recurrence.
  • Choledocholithiasis
• In one large study:
  • AAC (Acute Acalculous Cholecystitis): Removal in 2 weeks via the transhepatic route. [ preferred]
  • Removal in 3 weeks via the transperitoneal route.

Note

• LASEMS Placement: While LASEMS is useful in some gastrointestinal interventions, it is not typically used following cholecystostomy in patients unfit for cholecystectomy, making option D incorrect.

Early vs. Delayed Cholecystectomy in Acute Cholecystitis

MCQ 8

• Answer: c) Delayed - 15-30% did not respond to medical management during the acute episode
• Explanation:
  • a) Both early and delayed cholecystectomy have similar rates of common bile duct (CBD) injury and conversion to open surgery.
  • b) Early cholecystectomy is associated with more postoperative complications and a longer hospital stay compared to delayed cholecystectomy.
  • c) Delayed cholecystectomy poses a risk where 15-30% of patients may not respond to medical management during the acute episode, which makes it true.
  • d) Delayed cholecystectomy incurs more overall costs compared to early cholecystectomy.

Timing

• Early Cholecystectomy: Defined as surgery performed within 72 hours of symptom onset.
• Delayed Cholecystectomy: Performed 6-8 weeks after the acute episode to allow for inflammation to subside.

Acute Acalculous Cholecystitis

Pathogenesis

• Commonly Occurs In:
  • Patients with major acute illnesses (e.g., generalized sepsis, major trauma, burns).
  • Patients undergoing prolonged recovery from major operations and unable to tolerate oral intake.
• Mechanism:
  • Speculated Mechanisms: No stimulus for gallbladder contraction leading to bile stasis, formation of biliary sludge.
  • Contributing Factors: Ischemia, biliary stasis, sepsis, inspissated bile, and sludge.
• De Novo Presentation:
  • Increasing reports in outpatients, especially those with atherosclerotic vascular disease (e.g., hypertension, diabetes).
• Prevalence:
  • Represents 5% to 15% of all cases of acute cholecystitis.
  • Male Predominance: Unlike acute calculous cholecystitis, which is more common in women.

Clinical Manifestations

• Common Findings:
  • Fever
  • Right Upper Quadrant Pain
  • Leukocytosis
  • Hyperbilirubinemia
• Complications:
  • Increased incidence of gangrene and perforation compared to acute calculous cholecystitis, due to delayed diagnosis.
  • Severe complications are more common in older patients with elevated WBC counts.
  • Risk of Severe Complications: 50% to 60%.
  • Mortality Rate: As high as 15% in some series.

Diagnostic Evaluation and Imaging

• Ultrasound (US):

  • Findings: Gallbladder distension, thickened gallbladder wall, biliary sludge without stones.
  • Challenges: Interpretation difficult in critically ill patients; findings may be present in many critically ill, parenteral nutrition-dependent patients.

  • Accuracy: Varies by institution; some studies report high sensitivity and specificity, while others report lower accuracy.

    

• Computed Tomography (CT):

  • More sensitive and specific than US, but requires transport outside the ICU.
• Hepatobiliary Scintigraphy:
  • Previously associated with high false-positive rates.
  • More recent evaluations show improved accuracy.
  • May be more sensitive than CT or US in diagnosing acalculous cholecystitis.
  • Morphine Augmentation: Improves specificity by constricting the sphincter of Oddi and improving gallbladder filling, reducing false positives.

Treatment

• Definitive Treatment: Cholecystectomy (often performed laparoscopically).
• Percutaneous Cholecystostomy:
  • Used in critically ill patients to decompress the gallbladder and drain infected bile.
  • May serve as definitive treatment because there is no chronic obstruction of the gallbladder outlet.

MCQ 9

• Answer: a) Occurs exclusively in trauma, ICU, and prolonged surgical patients
• Explanation:
  • a) Incorrect because while acute acalculous cholecystitis commonly occurs in trauma, ICU, and prolonged surgical patients, it is not exclusive to these populations. There are increasing reports of de novo presentations in outpatients, particularly those with atherosclerotic vascular disease.
  • b) CT is indeed more sensitive and specific than US.
  • c) The risk of severe complications like perforation and gangrene is indeed 50-60%.
  • d) Acute acalculous cholecystitis does have a male preponderance.

Complications of Cholecystitis:

1. Gangrenous Cholecystits
2. Empyema
3. Emphysematous Cholecystitis
4. Mirizzi Syndrome
5. Cholecystoenteric Fistula
6. Bouveret Syndrome

Cholecystoenteric Fistula

• Definition: A cholecystoenteric fistula is a rare complication of acute cholecystitis where the gallbladder perforates into an adjacent hollow organ, typically the duodenum or transverse colon.
• Clinical Features:
  • Pneumobilia: Presence of air in the biliary tree, often seen with or without cholangitis.
  • Gallstone Ileus: 10% to 15% of patients with cholecystoenteric fistula develop gallstone ileus, where gallstones pass into the small intestine, causing bowel obstruction.
  • Chronic Diarrhea: Common presenting symptom in patients with cholecystocolonic fistula in nonemergent cases.
• Associations:
  • This complication occurs most frequently in women in their sixth to seventh decades
  • Frequently associated with Mirizzi syndrome or other hepatobiliary abnormalities such as gallbladder cancer.
• Treatment:
  • Cholecystectomy: With takedown and closure of the fistula.
  • Gallstone Ileus: Requires removal of the obstructing stone via enterotomy, and a thorough examination of the bowel for other stones.
  • Staged Surgery: If the patient is unstable or if inflammation is severe, fistula takedown and cholecystectomy may be delayed.

Bouveret Syndrome

• Definition: Gastric outlet obstruction secondary to gallstone impaction, facilitated by a bilioenteric fistula.
• Epidemiology:
  • Represents only 1% to 3% of all cases of gallstone ileus.
  • Gallstone Ileus: Occurs in less than 0.5% of patients with clinically relevant cholelithiasis.
• Risk Factors:
  • Female gender, older age, and stones greater than 2.5 cm in diameter.
• Symptoms:
  • Nausea, abdominal pain, and complete foregut outlet obstruction.

• Diagnosis:

  • Rigler’s Triad on abdominal plain films
    1. E/o Intestinal Obstruction: dilated stomach,
    2. pneumobilia, and
    3. E/o Calculi: a radio-opaque duodenal shadow.
  • US: Provides more anatomical detail but has variable sensitivity.
  • CT: Contrast-enhanced multi-detector CT is more sensitive and allows for simultaneous evaluation of the fistula and surrounding structures.
  • Esophagoduodenoscopy: Most sensitive and can be therapeutic.

  

• Treatment:

  • Endoscopic Removal: Preferred initial approach, though successful in only 10% of cases.
  • Surgical Approach:
    • Enterolithotomy with or without closure of the fistula and cholecystectomy, usually performed in stages.
    • Enterolithotomy Alone: Often preferred in older patients to minimize surgical risk.

MCQ 10

• Answer: d) Exclusively in cholelithiasis patients
• Explanation:
  • a) Correct, as pneumobilia is a typical finding, sometimes accompanied by cholangitis.
  • b) Correct, 10-15% of patients with cholecystoenteric fistula develop gallstone ileus.
  • c) Correct, Bouveret syndrome represents only 1-3% of all cases of gallstone ileus.
  • d) Incorrect because cholecystoenteric fistula is not exclusive to cholelithiasis patients; it may also be associated with conditions likeM irizzi syndrome or gallbladder cancer.and also seen in Peptic Ulcers, Rarely in Parasitic Infections.

Indications for Laparoscopic Cholecystectomy (LC) in Tokyo Grade II or III Acute Cholecystitis:

• Patient Eligibility:
  • Tokyo Grade II or III Acute Cholecystitis: LC should be considered for patients with these grades of cholecystitis if they meet the following criteria:
    • Charlson Comorbidity Index: Less than 6.
    • ASA Class: 2 or less.
    • Functional Status: Good functional status.
    • Organ System Failure:
      • Patients with cardiovascular or renal organ system failure that is rapidly reversible during admission are considered good candidates.

Critical View of Safety (CVS) in Laparoscopic Cholecystectomy

Doublet Scoring of CVS :

Criteria for Achieving Critical View of Safety (CVS)

• Two Structures Connected to Gallbladder:
  • Only two structures (cystic duct and cystic artery) should be clearly seen entering the gallbladder.
• Cystic Plate:
  • Approximately one-third of the cystic plate must be clearly visible.
• Clearance of Hepatocystic Triangle:
  • The hepatocystic triangle should be cleared of tissue to ensure visibility of the cystic structures and the cystic plate. However, the critical point is to ensure that no other structures are present in this area, making the surgeon certain about the identification of the cystic duct and artery.
• Liver Visibility:
  • The liver should be seen both anteriorly and posteriorly, with only the cystic duct and cystic artery crossing this view.

MCQ 11

• Answer: c) Tissues in Calot's triangle cleared
• Explanation: While it is crucial to clear the hepatocystic triangle to ensure proper visualization, the statement “Tissues in Calot's triangle cleared” is misleading if interpreted as entirely removing all tissues indiscriminately. The goal is to clear the Hepatocystic triangle.

Contraindications for Laparoscopic Cholecystectomy

Absolute Contraindications

• Refractory Coagulopathy:
  • Patients with refractory coagulopathy are at a high risk for bleeding complications, making this an absolute contraindication to laparoscopic cholecystectomy.
• Intolerance to General Anesthesia:
  • If a patient cannot tolerate general anesthesia, they cannot undergo laparoscopic cholecystectomy.

Relative Contraindications

• Severe Cardiopulmonary Disease:
  • While this is a relative contraindication, the decision to proceed with surgery depends on the patient’s overall clinical condition and the surgeon's judgment.
• Pregnancy:
  • Considered a relative contraindication, especially in the first and third trimesters, though laparoscopic cholecystectomy can still be performed with appropriate precautions.
• Cirrhosis with Portal Hypertension:
  • Laparoscopic cholecystectomy is challenging in patients with cirrhosis and portal hypertension due to the risk of bleeding, but it is not an absolute contraindication. The decision is based on the patient's specific condition and surgical risk.

MCQ 12

• Answer: d) Refractory coagulopathy
• Explanation:
  • d) Refractory coagulopathy is an absolute contraindication because it significantly increases the risk of bleeding during surgery, which cannot be safely managed with laparoscopic techniques. This makes it unsafe to proceed with laparoscopic cholecystectomy.
  • a) Severe cardiopulmonary disease, while serious, is a relative contraindication and not absolute.
  • b) Pregnancy is also a relative contraindication, with surgery being possible depending on the trimester and clinical scenario.
  • c) Cirrhosis with portal hypertension, although challenging, is not an absolute contraindication and may be managed with careful surgical planning and technique.

Postcholecystectomy Diarrhea

Definition and Characteristics

• Definition: Postcholecystectomy diarrhea is characterized by the passage of three or more loose stools per day following the removal of the gallbladder.
• Type of Diarrhea: Secretory type, likely due to the continuous flow of bile into the gut leading to an increased number of bile salts in the colon.
• Etiology:
  • Multifactorial: One contributing factor may be the increased bile salts in the colon.
  • Altered Gut Microbiome: Patients with postcholecystectomy diarrhea have been shown to have significantly higher levels of Proteobacteria, which may play a pathogenic role.

Management

• Bile-Acid Binding Agents: Cholestyramine ; Recommended as a primary therapy, although results can be variable.
• Antidiarrheals: Can be used to manage symptoms.
• UDCA (Ursodeoxycholic Acid): Not recommended for managing postcholecystectomy diarrhea.

MCQ 13

• Answer: c) Managed with UDCA
• Explanation:
  • c) UDCA is not recommended for managing postcholecystectomy diarrhea. The management typically involves bile-acid binding agents and antidiarrheals, but UDCA is not part of the standard treatment protocol for this condition.
  • a) Correct, as postcholecystectomy diarrhea is defined by passing three or more loose stools per day.
  • b) Correct, it is a secretory type of diarrhea due to increased bile salts in the colon.
  • d) Correct, antidiarrheals can be used to manage symptoms.

Choledocholithiasis During Elective Laparoscopic Cholecystectomy

Incidence and Detection

• Overall Incidence: 10-15% of choledocholithiasis cases are incidentally diagnosed during elective laparoscopic cholecystectomy.
  • Intraoperative Cholangiography (IOC): Detects choledocholithiasis in 4.6% of cases.
  • ERCP After 6 Weeks: Detects choledocholithiasis in 2.2% of cases.
  • Silent Stones: Many stones pass without causing symptoms, suggesting that only selective patients should be subjected to cholangiography.

EUS vs. MRCP for Detecting Choledocholithiasis

• EUS (Endoscopic Ultrasound) vs. MRCP (Magnetic Resonance Cholangiopancreatography):
  • Detecting Small Stones: EUS is more effective (97% vs. 90% detection rate).
  • Special Considerations:
    • Obesity: EUS preferred.
    • Claustrophobia: EUS preferred.
    • Presence of Metal Clips/Pacemaker: EUS preferred.
    • Unable to Hold Breath: EUS is a better option.
  • EUS Advantage: Allows for immediate ERCP if needed.

MCQ 14

• Answer: d) ALP > 400 IU/L
• Explanation:
  • a) Visualization of choledocholithiasis on imaging is a very strong predictor, leading directly to ERCP.
  • b) Ascending cholangitis is a very strong predictor that warrants immediate ERCP.
  • c) Bilirubin > 4 mg/dL is also a very strong predictor for choledocholithiasis, requiring ERCP.
  • d) ALP > 400 IU/L is a moderate predictor and does not independently warrant direct ERCP without other strong or very strong predictors present.

ASGE Guidelines Overview

• Very Strong Predictors: Visualized CBD stone on imaging, cholangitis, or bilirubin > 4 mg/dL. ⇒ directly ERCP
• Strong Predictors: Dilated CBD > 6 mm, bilirubin between 1.8 and 4 mg/dL. ⇒ if both present ⇒ Directly ERCP
• Moderate Predictors: Other abnormal liver function tests, age > 55 years, gallstone pancreatitis.
  • Intermediate-Risk Patients: Should undergo preoperative MRCP or EUS, followed by ERCP if stones are visualized, or proceed with laparoscopic cholecystectomy with an intraoperative cholangiogram.
• Low-Risk Patients: No very strong, strong, or moderate predictors should proceed directly to cholecystectomy.

Post-ERCP Pancreatitis

Key Statistics and Risk Factors

• Overall Incidence: 9.7%
• Incidence in High-Risk Patients: 14.7%
• Resulting Mortality: 0.7%
• Trend Over Time: The incidence of post-ERCP pancreatitis has not reduced in the last two decades, making this a significant concern in clinical practice.

Risk Factors for Post-ERCP Pancreatitis

• Suspected Sphincter of Oddi Dysfunction
• Prior History of Post-ERCP Pancreatitis
• Female Patients
• Young Age
• Difficult Cannulation
• Contrast Injections into the Pancreatic Duct

Preventive Measures

• PR Indomethacin/Diclofenac: Prophylactic administration of these medications or placing a pancreatic duct stent can reduce the risk of post-ERCP pancreatitis by 50%.
• Protease Inhibitor (Nafamostat): Currently under trial for reducing the risk of post-ERCP pancreatitis.

MCQ 15

• Answer: d) It has reduced in the last two decades
• Explanation:
  • d) Incorrect because the incidence of post-ERCP pancreatitis has not reduced in the last two decades, which remains a significant concern for clinicians.
  • a) Correct, the overall incidence is 9.7%.
  • b) Correct, the incidence in high-risk patients is 14.7%.
  • c) Correct, the resulting mortality from post-ERCP pancreatitis is 0.7%.

Open Common Bile Duct Exploration (CBDE)

Indications for Open CBD Exploration

• Large or Impacted CBD Stones: Especially in patients who have failed previous endoscopic interventions.
• Biliary Enteric Drainage: Required when there is a need for biliary drainage into the intestine.
• Anatomic Considerations: Conditions that preclude endoscopic treatment, such as:
  • Prior gastric resection
  • Gastric bypass
  • Duodenal diverticula
• Complex Surgical Situations:
  • Mirizzi syndrome
  • Biliary-enteric fistula
  • Severe cholecystitis
  • High index of suspicion for cancer

Indications for Bilioenteric Drainage in Re-Surgery for CBD Calculi

• Stricture or Stenosis: Of the distal bile duct or sphincter of Oddi.
• Marked Dilation: Of the duct to 2 cm or more.
• Multiple or Primary Bile Duct Stones.
• Inability to Remove All Stones: From the duct.
• Third Operation: When a third surgery is required.

MCQ 16

• Answer: b) Flexible choledochoscope length is 7 cm, reaching ampulla is easy
• Explanation:
  • a) Correct, opening close to the duodenum preserves the long upper CBD, which is beneficial if further surgery or bypass is needed later.
  • b) Incorrect, as earlier rigid scopes were around 7 cm in length, but modern flexible scopes are longer, so the length is no longer a limiting factor.
  • c) Correct, opening near the duodenum allows for easier maneuvering during the procedure.
  • d) Correct, opening close to the duodenum makes anastomosis with the duodenum easier, if needed.

Transduodenal Sphincteroplasty

• With advent of ERCP this procedure usage has comedown significantly

T tube after cbd exploration there are 3 options: 1) closed primarily 2) T tube placement 3) bilioenteric anastomosis = indications are already seen above

if we are sure of complete clearance = closed primarily

if we are not sure of complete clearance or not stable enough to undergo complete clearance like cholangitis and PTC not possible then T tube placement is done

T-Tube Cholangiography and Management in Open CBD Exploration

Purpose of T-Tube Cholangiography

• Assessment of Biliary Clearance: T-tube cholangiography is performed after T-tube insertion and choledochotomy closure to ensure the biliary system is clear of residual stones.
• Detection of Residual Stones: If residual stones are detected, the T-tube may need to be removed, and the CBD re-explored, requiring a second closure.
• Placement Check: Helps in identifying incorrect placement of the T-tube, preventing post-operative complications.

T-Tube Drainage

• Purpose: T-tube drainage is used to allow for the resolution of sphincter spasm or edema after CBD exploration, thereby preventing increased pressure in the biliary system and potential bile leakage.
• Questionable Routine Use: Studies show that routine T-tube use does not necessarily decrease bile leak risk and may increase operative time and hospital stay.
• Interventional Role: The T-tube provides a route for future interventions, such as radiologic stone removal or choledochoscopy, especially in high-risk patients.

T-Tube Placement

• Customization: The T-tube size should match the diameter of the CBD, with 14-Fr being the smallest recommended size.
• Shortening the Limbs: The limbs of the T-tube should be shortened to prevent obstruction or difficulty in extraction. Dividing the back wall of the T-tube should be minimized to avoid complications during interventional procedures.
• Proper Placement: The long limb of the T-tube should emerge under the costal margin laterally, and care must be taken to avoid catching the tube in sutures during choledochotomy closure.

Postoperative Management

• Initial Drainage: Bile is allowed to drain freely into a bile bag to relieve any pressure caused by sphincter spasm or edema.
• Monitoring: Persistently high external bile volume suggests distal obstruction or incorrect T-tube placement, while no external drainage may indicate blockage or dislodgment.
• T-Tube Cholangiography: Performed 5 to 7 days postoperatively to confirm normal bile flow before tube removal.
• Residual Stones: If stones are detected on cholangiography, a wait-and-see approach is often taken unless the patient shows signs of cholangitis or rising bilirubin. Stones may pass spontaneously, with further cholangiography after 5 weeks if needed.

Endoscopic Papillary Large Balloon Dilatation (EPLBD)

Overview

Endoscopic Papillary Large Balloon Dilatation (EPLBD) is a recent advancement in the endoscopic management of choledocholithiasis, particularly for removing large bile duct stones. This technique allows for the safe and effective removal of stones without the need for extensive cutting of the sphincter, reducing the risks associated with traditional Endoscopic Sphincterotomy (EST).

Key Principles of EPLBD

1. Indication for EPLBD:
   • Dilated CBD without Distal CBD Strictures: EPLBD is particularly indicated when the common bile duct (CBD) is dilated, and there are no strictures in the distal CBD that might complicate the procedure.
2. Avoid Full Endoscopic Sphincterotomy (EST):
   • Prevention of Perforation and Bleeding: It is advisable to avoid performing a full endoscopic sphincterotomy immediately before large balloon dilatation. This reduces the risk of perforation and bleeding, which are potential complications of extensive sphincterotomy.
3. Gradual Balloon Inflation:
   • Detection of Occult Strictures: The balloon should be inflated gradually. Slow inflation helps in identifying any occult strictures that might be present, allowing the endoscopist to adjust the procedure accordingly.
4. Responding to Resistance During Inflation:
   • Discontinue if Resistance is Met: If resistance is encountered during balloon inflation, indicated by the presence of a persistent balloon waist, it is essential to stop the inflation. This may suggest an underlying stricture or other issues that need to be addressed before continuing.
5. Balloon Inflation Limits:
   • Do Not Exceed CBD Size: The balloon should not be inflated beyond the maximal size of the upstream dilated CBD. Overinflation can lead to complications such as perforation or injury to the duct.
6. Alternative Stone Removal Techniques:
   • Switching to Alternative Methods: If there is difficulty in removing the stones after EPLBD, it is important not to hesitate in converting to alternative methods. These may include:
     • Mechanical Lithotripsy (ML): A technique used to crush large stones that cannot be removed by standard endoscopic methods.
     • Electrohydraulic Lithotripsy (EHL): A method that uses shock waves to fragment stones, making them easier to remove.

Clinical Considerations

• EPLBD is a useful technique for managing large bile duct stones, particularly when traditional methods might pose a higher risk of complications.
• Caution and careful technique are paramount to avoid complications such as perforation, bleeding, or failure to remove stones effectively.
• Alternative techniques should be readily available during EPLBD procedures to ensure successful stone removal in challenging cases.

Choledocholithiasis (CBD Stones)

Silent Common Bile Duct (CBD) Stones

• Prevalence:
  • 12% of CBD stones identified during routine intraoperative cholangiography (IOC) are clinically silent, meaning they do not present with symptoms.
  • 6% of these silent CBD stones do not cause abnormalities in liver function tests (LFTs) or CBD dilatation, making detection challenging.
• Natural History:
  • Spontaneous Passage: Data suggest that more than one-third of asymptomatic stones will pass spontaneously within the first 6 weeks after cholecystectomy without causing symptoms.
• Management:
  • Routine Removal: Despite being asymptomatic, it is generally recommended that CBD stones be removed due to the potential risk of developing complications.

Symptomatic Common Bile Duct (CBD) Stones

• Symptoms:
  • Symptoms of CBD stones arise from partial or complete biliary obstruction and may include:
    • Jaundice
    • Itching
    • Dark urine
    • Acholic stools
  • These stones can also lead to more severe complications such as:
    • Cholangitis
    • Hepatic abscesses
    • Pancreatitis
• Complications:
  • Chronic Biliary Obstruction: Prolonged obstruction due to CBD stones can result in secondary biliary cirrhosis and portal hypertension.
• Management:
  • Given the risk of serious complications, symptomatic CBD stones should be promptly identified and removed.

MCQ 17

• Answer: d) More common in patients with acute cholecystitis
• Explanation: Silent CBD stones are not more common in patients with acute cholecystitis. These stones are often discovered incidentally during procedures like IOC and are not necessarily associated with acute symptoms or conditions.

Endoscopic Retrograde Cholangiopancreatography (ERCP) in Acute Biliary Pancreatitis

Key Points for Revision

• Mechanisms of Gallstone Pancreatitis:
  • Reflux of bile into the pancreatic duct.
  • Transient ampullary obstruction due to a temporarily impacted stone in the ampulla.
• Severity of Disease:
  • Mild Pancreatitis: Occurs in approximately 80% of patients.
  • Severe Pancreatitis: Occurs in 20% of patients and can lead to complications such as pancreatic necrosis, multisystem organ failure, and death.
• Management Based on Severity:
  • Mild Pancreatitis: ERCP is generally not recommended unless there are additional complications like cholangitis or biliary obstruction. These patients should undergo elective cholecystectomy once pancreatitis resolves, preferably during the same hospitalization.
  • Severe Pancreatitis (Ranson >3, APACHE II >8):
    • Without Cholangitis: Early biliary decompression (ERCP) should be performed within 24-72 hours of admission if there's a worsening clinical scenario or persistent biliary obstruction.
    • With Cholangitis: ERCP should be performed within 24 hours to relieve the obstruction.
  • Multiorgan Dysfunction Syndrome (MODS): In patients with MODS, early biliary decompression (within 24 hours) is critical, though this may be influenced by the patient's stability.
• Risk of Recurrence:
  • Recurrence rates of gallstone pancreatitis can be high (up to 76%) if cholecystectomy is not performed during the index hospitalization.
  • ERCP with sphincterotomy reduces the 5-year recurrence rate to 11.1% compared with 22.7% in patients who undergo no intervention.

MCQ 18

• Answer: c) With MODS - within 24 hours
• Explanation: While ERCP is critical in managing severe cases of biliary pancreatitis, in patients with MODS, intervention timing may be influenced by the patient’s overall stability and other factors. However, the general recommendation is that ERCP should be performed within 24 hours if cholangitis or biliary obstruction is present, irrespective of MODS. The other statements are accurate in terms of timing and the recommended approach based on clinical severity.

Acute Cholangitis

Key Points for Revision

• Charcot’s Triad (1877):
  • Classic triad of symptoms: Right Upper Quadrant (RUQ) pain, jaundice, fever, and chills.
  • Specificity: High specificity but low sensitivity—only 50% to 70% of patients present with all three symptoms.
• Reynold’s Pentad (1959):
  • Charcot’s Triad + Shock + Altered Mental Status.
  • Indicative of severe (Grade III) cholangitis, often with multiorgan dysfunction.
• Prevalence of Severe Cholangitis:
  • Reported in 12% to 30% of patients with acute cholangitis.

• 2013/2018 Tokyo Guidelines:

  • Diagnosis:

    • Based on systemic inflammation, cholestasis, and imaging findings.
    • Suspected Diagnosis: Systemic inflammation + cholestasis or biliary obstruction.
    • Definitive Diagnosis: Systemic inflammation + cholestasis and biliary obstruction.

    

  • Sensitivity and Specificity:

    • Sensitivity: 91.8%
    • Specificity: 77.7%
  • Pathophysiology:
  • Localized Infection: Often due to bacteria-laden gallstones.
  • Cholangiovenous Reflux: Occurs with biliary pressures > 20 cm H₂O, leading to bacteremia and organ dysfunction.
  • Common Pathogens:
  • Escherichia coli
  • Klebsiella spp.
  • Enterococcus
  • Enterobacter cloacae
  • Pseudomonas spp.
  • Anaerobic pathogens
  • Grades of Cholangitis (2013/2018 Tokyo Guidelines):
  • Grade I (Mild): Responds to medical therapy and can proceed to ERCP or cholecystectomy after stabilization.
  • Grade II (Moderate): Requires urgent biliary decompression.
  • Grade III (Severe): Associated with organ failure, requires urgent biliary drainage (ERCP or PTC) after stabilization of organ dysfunction.

• Treatment:
  • Biliary Decompression: Crucial to prevent cholangiovenous reflux and reduce endotoxin levels.
  • ERCP: Preferred for biliary drainage; PTC may be used if ERCP is not available.
  • Surgical Drainage: Reserved for cases where noninvasive approaches are not feasible.
• Need for Cholecystectomy After ERCP/Sphincterotomy:
  • Recommended to decrease mortality, recurrent biliary symptoms, and the need for repeat interventions.
  • Watchful Waiting: Considered in high-risk patients with prohibitive surgical risks.

Gallstone Disease Associated with Pregnancy

Key Points for Revision

• Traditional Concerns:
  • Historically, surgery was avoided in the first and third trimesters due to concerns about spontaneous abortion and preterm labor.
• Laparoscopic Cholecystectomy:
  • Recommended Across All Trimesters: Recent studies support the safety and efficacy of laparoscopic cholecystectomy for cholecystitis in all trimesters of pregnancy.
  • Fetal and Maternal Outcomes: Meta-analysis shows decreased rates of fetal and maternal complications with laparoscopic surgery compared to open cholecystectomy, with a shorter hospital stay.
  • Technical Considerations:
    • Patient Positioning: Partial left lateral decubitus to prevent compression of the inferior vena cava (IVC).
    • Port Placement: Adjusted for fundal height, with safe access typically via a right subcostal trocar.
    • Insufflation Pressure: Standard pressures can be used but should be adjusted based on hemodynamics.
• Complicated Biliary Disease:
  • Increased Risk: Complicated biliary disease in pregnancy significantly increases the risk of spontaneous abortion and preterm labor.
  • High Recurrence Rates: If managed conservatively, recurrence rates of symptomatic cholelithiasis are 92% in the first trimester, 64% in the second trimester, and 44% in the third trimester.
  • Guideline Recommendations: The 2017 SAGES guidelines advocate for laparoscopic cholecystectomy in all trimesters for cholecystitis to reduce these risks.
• Mild Disease:
  • Conservative Management: Generally safe for mild cases, with no significant difference in rates of preterm labor or spontaneous abortion when compared to surgical management.

MCQ 19

• Answer: d) Mild disease - conservative management increases the chance of preterm labor and not abortion
• Explanation: Conservative management of mild gallstone disease in pregnancy does not increase the chance of preterm labor or spontaneous abortion. In fact, there is no significant difference in outcomes between conservative management and surgical intervention in mild cases. The other statements are true regarding the management of gallstone disease in pregnancy.