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Choledocholithiasis [S+DT]

Predictors of Choledocholithiasis:

| Very Strong | | --- | | 1. CBD stone on TUS | | 2. Clinical Ascending Cholangitis | | 3. Bilirubin > 4mg/dl | | Strong | | 1. Dilated CBD on TUS (>6mm with gallbladder insitu) | | 2. Bilirubin 1.8-4 mg/dl | | Moderate | | 1. Abnormal liver biochemical test not including bilirubin concentration ( eg ALP elevation) | | 2. Age > 55yrs | | 3. Clinical Gallstone Pancreatitis | | Assessing a likelihood of choledocholithiasis based on clinical predictors | | Presence of ANY very strong predictor HIGH | | Presence of BOTH strong predictors HIGH | | No predictors present LOW | | All other patients Intermediate | - If there are any very strong predictors or both strong predictors ⇒ no need for EUS / MRCP ⇒ we directly manage these patients with any of the options: - Preop ERCP + Lap Chole = preferred - Lap Chole + Intra op Cholangiography ⇒ stone clearance = if expert in lap surgery

  • If INTERMEDIATE RISK (eg : any one strong predictor/ Moderate predictors) ⇒ EUS / MRCP has to be done to confirm CBD stones
  • If the CBD is normal in size and CBD stones are present:
    • Preferred ⇒ ERCP
    • 2nd preferred ⇒ Transcystic approach
    • dont go for Choledochotomy (intra op) = Increased chances of stricture formation

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Choledocholithiasis During Elective Laparoscopic Cholecystectomy [DT]

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.
  • Strong Predictors: Dilated CBD > 6 mm, bilirubin between 1.8 and 4 mg/dL.
  • Moderate Predictors: Other abnormal liver function tests, age > 55 years, gallstone pancreatitis.
  • Low-Risk Patients: No very strong, strong, or moderate predictors should proceed directly to cholecystectomy.
  • 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.

Management of Choledocholithiasis [ SKF chapter 109]

Overview of Treatment Options

Choledocholithiasis, or common bile duct (CBD) stones, is a common condition requiring intervention. The treatment options include:

  • Laparoscopic Common Bile Duct Exploration (LCBDE): A surgical method to explore and clear stones from the CBD.
  • Endoscopic Retrograde Cholangiography (ERC) with or without Endoscopic Sphincterotomy (ES): A nonsurgical method that uses endoscopy to remove stones from the CBD.
  • Percutaneous Transhepatic Cholangiography (PTC): An interventional radiology approach to access the biliary tree.

Factors Influencing Treatment Choice:

  • Patient factors:
    • Comorbidities that increase the risk of surgery.
    • Timing of CBD stone diagnosis (preoperative, intraoperative, or postoperative).
  • Health care facility capability:
    • Availability of endoscopic or interventional radiology support.

Detection of Common Duct Stones

Clinical Presentations of Choledocholithiasis:

  • Cholangitis: Most predictive of choledocholithiasis, with studies showing 100% specificity.
  • Other presentations (less predictive):
    • Cholecystitis
    • Pancreatitis
    • Biliary colic
    • Jaundice

Incidence of CBD Stones Based on Clinical Presentation:

  • Cholecystitis: 7%
  • Biliary colic: 16%
  • Pancreatitis: 20%
  • Jaundice: 45%

Diagnostic Tools:

  1. Transabdominal Ultrasonography:
    • Common initial imaging modality.
    • Sensitivity: 50%–80% depending on CBD dilation.
  2. Endoscopic Retrograde Cholangiography (ERC):
    • High specificity for diagnosing CBD stones.
    • Therapeutic potential: Sphincterotomy and duct clearance.
    • Risks: Post-ERC pancreatitis, bleeding, sepsis, and perforation (15.9% morbidity, 1% mortality).
    • Up to 60% of patients may undergo unnecessary ERC due to the absence of stones.
  3. Endoscopic Ultrasound (EUS):
    • Sensitivity: 98%, Specificity: 99%.
    • Recommended for symptomatic patients with indeterminate risk of choledocholithiasis.
    • Lower risk of pancreatitis compared to ERC.
  4. Magnetic Resonance Cholangiopancreatography (MRCP):
    • Useful for diagnosing choledocholithiasis, with a positive predictive value of 95%.
    • Preferred in patients with indeterminate risk and those with prior gastric bypass surgery.
    • Non-invasive, but lacks therapeutic capabilities and is expensive.

Preoperative Endoscopic Therapy

  • ERC plays a critical role in the treatment of common duct stones, especially for:
    • Older adults or debilitated patients.
    • Patients presenting with jaundice, cholangitis, or severe pancreatitis.
  • For patients unfit for surgery, ERC/ES with the gallbladder left in situ is an option, with up to 85% symptom-free at 70-month follow-up.
  • Decreased mortality has been observed in patients undergoing ERC versus surgical drainage for cholangitis and severe pancreatitis.

Timing of Surgery after Successful Preoperative ERC:

  • Early laparoscopic cholecystectomy (LC) should be considered after successful ERC due to a 36% recurrence of biliary events within 6–8 weeks.

Single-Stage vs. Two-Stage Management

  • Two-Stage: Preoperative ERC/ES followed by LC.
  • Single-Stage: LCBDE and LC in one session.
    • Equivalent success rates for both approaches.
    • Single-stage LCBDE reduces hospital stay and costs compared to two-stage management.

Morbidity Associated with ERC/ES

  • Much of the morbidity is linked to sphincterotomy.
  • Endoscopic Papillary Dilation:
    • An alternative to sphincterotomy, but associated with a higher risk of pancreatitis.
    • Recommended in patients with coagulopathy as the preferred method for stone removal.

Conclusion

  • Laparoscopic CBD exploration (LCBDE) is a key surgical technique in the management of choledocholithiasis, providing a one-stage solution in many cases.
  • Endoscopic methods like ERC and EUS offer nonsurgical alternatives, with ERC also serving as a therapeutic option.
  • The choice of treatment depends on patient factors, the timing of diagnosis, and the available resources at the healthcare facility.

Intraoperative Diagnosis and Management of Common Bile Duct Stones

Indications for Intraoperative Imaging

  • During Laparoscopic Cholecystectomy (LC), the common bile duct (CBD) should be imaged if:
    • Suspected choledocholithiasis:
      • Past or present elevation of liver function tests
      • Gallstone pancreatitis
      • CBD dilation
      • Choledocholithiasis on preoperative ultrasound
    • Unclear biliary anatomy

Methods of Intraoperative Imaging

1. Intraoperative Cholangiography (IOC)

  • Preparation:
    • Apply a clip high on the cystic duct at its junction with the gallbladder to prevent stone migration.
    • Partially transect the cystic duct and milk stones away from the CBD.
  • Procedure:
    • Insert a cholangiography catheter into the cystic duct.
    • Secure the catheter with a clip, grasping jaws, or balloon fixation.
    • Perform cholangiography with real-time fluoroscopy using 5–10 mL of diluted water-soluble contrast.
  • Assessment Goals:
    1. Determine the length of the cystic duct and its junction with the CBD.
    2. Assess the size of the CBD.
    3. Identify any intraluminal filling defects (stones).
    4. Confirm free flow of contrast into the duodenum.
    5. Visualize the anatomy of the biliary tree.

2. Laparoscopic Ultrasonography (LUS)

  • Alternative to IOC with greater sensitivity and equal specificity.
  • Advantages:
    • Better resolution than transabdominal ultrasonography.
    • Faster procedure time (~7 minutes vs. 13 minutes for IOC).
    • Avoids ionizing radiation.
  • Limitations:
    • Less effective in delineating intrahepatic anatomy.
    • May miss anatomic anomalies of the ductal system.
  • Conclusion: LUS and IOC are complementary techniques.

A. Laparoscopic Common Bile Duct Exploration (LCBDE)

Approaches:

1. Transcystic Technique

  • Indications:
    • Small stones (<2–3 mm).
    • Stones that can be flushed into the duodenum.
  • Procedure:
    • Administer intravenous glucagon (1–2 mg) to relax the sphincter of Oddi.
    • Perform vigorous flushing with 100–200 mL of saline.
    • If flushing fails:
      • Use a helical stone basket over a guidewire under fluoroscopic guidance.
      • Employ a choledochoscope (≤10 French) after balloon dilation of the cystic duct (up to 8 mm).
  • Post-Procedure:
    • Conduct a completion cholangiogram or ultrasound to confirm duct clearance.
    • Ligate the cystic duct stump due to tissue edema.
  • Success Rate: 80%–98% in recent series.
  • Complications:
    • Infection, pancreatitis (5%–10%).
    • Mortality rate of 0%–2%.
  • Limitations:
    • Not suitable for large or multiple stones, stones in proximal ducts, small or tortuous cystic ducts.

2. Laparoscopic Choledochotomy

  • Indications:
    • Multiple or large stones.
    • Stones in proximal bile ducts.
    • CBD diameter larger than 8–10 mm.
  • Procedure:
    • Place stay sutures on either side of the anterior CBD wall.
    • Make a longitudinal choledochotomy on the distal CBD.
    • Remove stones under endoscopic visualization.
  • Closure Options:
    • Primary closure of the ductotomy.
    • Closure over a T tube or C tube.
  • Post-Procedure:
    • Place an active drain in the subhepatic space.
    • If a T tube is used, perform a final cholangiogram 14–21 days postoperatively.
  • Success Rate: 84%–94%.
  • Complications:
    • CBD laceration, bile leak, sewn-in T tubes, stricture formation.
  • Note: No biliary strictures reported in studies with long-term follow-up.

Alternative Techniques:

3. Transcystic Balloon Dilation of the Sphincter of Oddi

  • Method: Balloon dilation to facilitate stone passage.
  • Success Rate: 85% in some studies.
  • Complications: Postoperative pancreatitis (15%).

4. Transcystic Antegrade Sphincterotomy

  • Procedure:
    • Insert a sphincterotome through the cystic duct to the ampulla.
    • Use a duodenoscope for proper positioning.
    • Perform sphincterotomy by applying current.
  • Outcome: Successful stone clearance without complications in some reports.

Postoperative Endoscopic Therapy (ERC/ES)

  • Indications:
    1. LCBDE fails to clear the duct.
    2. Surgeon inexperienced in LCBDE.
    3. Retained stones discovered postoperatively.
    4. Patient's comorbidities make prolonged surgery risky.
    5. Small CBD prone to postoperative stricture.
  • Considerations:
    • Maintains minimally invasive treatment goals.
    • Additional procedure with associated risks.
  • Success Rate: Clearance failure rate of 4%–18%.
  • Alternative Strategy:
    • Insert a transcystic catheter during LC to facilitate postoperative ERC.

Patients with Roux-en-Y Gastrojejunostomy

  • Anatomical Challenges:
    • Difficult access to CBD due to altered GI anatomy.
  • Management Strategies:
    • During LC:
      • Routine intraoperative cholangiogram with or without LCBDE.
    • If cholecystectomy already performed:
      • Obtain MRCP to confirm choledocholithiasis.
      • Attempt ERC with single- or double-balloon enteroscope (60%–80% success).
      • Consider laparoscopic-assisted ERC or laparoscopic choledochotomy if ERC fails.

B. Open Common Bile Duct Exploration (OCBDE)

  • Indications:
    • LCBDE and/or ERC are unsuccessful.
    • Impacted stone at the ampulla of Vater.

Procedures:

A. Sphincterotomy and Sphincteroplasty

  • Sphincterotomy:
    • Incise the distal sphincter musculature (~1 cm).
  • Sphincteroplasty:
    • Complete division of the sphincter muscle.
    • Suture approximation of the duodenal and CBD walls.
  • Procedure Steps:
    • Perform a generous Kocher maneuver.
    • Make a longitudinal duodenotomy.
    • Use a catheter or dilator to guide ampulla into the operative field.
    • Incise the ampulla and remove impacted stones.

B. Choledochoenterostomies

  • Choledochoduodenostomy:
    • Side-to-side anastomosis between the CBD and duodenum.
    • Suitable for dilated CBD (>2 cm) with multiple stones.
  • Procedure:
    • Perform a longitudinal choledochotomy and duodenotomy.
    • Create a "diamond-shaped" anastomosis with interrupted sutures.
  • Complications:
    • Sump syndrome: Rare; managed with ERC/ES.
  • Alternatives:
    • End-to-side choledochoduodenostomy.
    • Choledochojejunostomy.

Note: Management of CBD stones requires a tailored approach based on stone size, number, location, and patient-specific factors. Intraoperative imaging and exploration techniques enhance the success rate of stone clearance and reduce the need for additional procedures.