cbd stones
TRANSCRIPT
Introduction
Eleven to 21% of cholelithiasis have concomitant CBDS at the time of surgery
Majority of CBDS form in GB and then migrate CBD
Pass into the duodenum following the bile flow
May remain in the choledochus owing to the smaller diameter at the Vater papilla
Clinical presentation
Asymptomatic Colicky pain Cholecystitis Biliary obstruction Ascending cholangitis Acute Biliary pancreatitis
CBD stones - Endotherapy
Diagnosis US,MRCP, EUS and ERC
Endoscopic retrograde cholangiography (ERC) changed the approach to CBDS
Role of EUS
Diagnosis of CBDS Comparable to MRC More sensitive for
Biliary microcalculi Small stone impaction at ampulla Biliary sludge
Reduce ERC interventions
Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones
Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones
Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones
Difficult CBD Stone
Commonly refers to a stone > 15 mm in diameter Usually unable to make ES larger than 15 mm
Stones < 15 mm may be considered difficult if: Proximal to stricture Narrow intrapancreatic segment Impacted Multiple Intrahepatic Billroth II reconstruction ES length is limited – e.g., periampullary diverticulum
Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones
The variables affecting the success of stone extraction
Stone size and shape Bile duct diameter Bile duct geometry Composition of the stone Bile duct strictures distal to the stone
Endoscopic technical difficulty of CBD Stones
Older age (>65 years) Previous gastrojejunostomy Larger CBD stone (≥ 15 mm) Impacted CBD stone Use of mechanical lithotripsy Short length of the distal CBD arm (<36mm) Acute distal CBD angulation (<135 degrees) Relative narrowing of distal CBD
GIE 2007; 66:1154-60
Reasons for unsuccessful CBD stone removal
Anatomic obstacles to cannulation Postoperative states Billroth II gastroenterostomy Roux-en-Y anastomosis Anastamotic strictures Ampullary or duodenal tumor mass Scared duodenum from prior PUD Periampullary diverticulum Ampullary edema or inflammation
Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones
Endoscopic Management of Large Bile Duct Stones
Mechanical lithotripsy Intraductal shockwave lithotripsy
Electrohydraulic Laser
Extracorporeal shockwave lithotripsy Dissolution
MTBE Monooctanoin
Long term stents
Endoscopic Management of Large Bile Duct Stones
Mechanical lithotripsy Intraductal shockwave lithotripsy
Electrohydraulic Laser
Extracorporeal shockwave lithotripsy Dissolution
MTBE Monooctanoin
Long term stents
Mechanical Lithotripsy
Advantages Relatively easy to use Relatively low cost Prevents stone impaction Can be done at initial ERCP
Disadvantages Requires stone capture Very hard stones may not fragment Several baskets may be required for each patient
Bile Duct Stones
Failed Mechanical Lithotripsy
ESWL
Percutaneously Surgery
Cholangioscope- Laser- EHL Stent
Dissolve
Cholangioscope
Mother baby scope Two operators Fargile High repair costs No dedicated irrigation channel Limited two way steering
capability
Spyglass Single operator Four way steering capability Independent irrigation channel Diagnostic and therapeutic
capabiities
Endoscopic management of Calculous cholecystitis
Comorbidities Elderly Trans papillary GB stenting / drainage EUS guided cholecystoduodenostomy
Conclusions
Biliary lithiasis affects 10% to 20% of general population
CBDS in up to 20% Endoscopic removal successful in 80-90%
using standard techniques EUS has an important role and avoids
unnecessary ERC
Conclusions
Stone location, stone size, and bile duct features may render stones non extractable using standard retrieval techniques
Balloon sphincteroplasty helps in extracting bigger stone
Difficult stones mechanical lithotripsy is easiest and cheapest, if stone can be captured in basket
Conclusions
Using all endoscopic and ancillary techniques, stone clearance rate ~ 97%
Direct cholangioscopic stone removal could achieve near complete stone removal except in intra hepatic stones
CBDS management is multidisciplinary Tailored on available resources and
expertise