Cbd stones

Cbd stones

1. Biliary stone diseases
Mathew Philip
PVS Memorial hospital
Kochi

2. Prevalence of gallstones by age
and gender

3. 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

4. Clinical presentation
Asymptomatic
Colicky pain
Cholecystitis
Biliary obstruction
Ascending cholangitis
Acute Biliary pancreatitis

5. CBD stones - Endotherapy
Diagnosis
US,MRCP, EUS and ERC
Endoscopic retrograde cholangiography
(ERC) changed the approach to CBDS

6. Role of EUS
Diagnosis of CBDS
Comparable to MRC
More sensitive for
Biliary microcalculi
Small stone impaction at ampulla
Biliary sludge
Reduce ERC interventions

8. Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones

9. Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones

10. Standard treatment of CBD stnes

14. Standard Treatment of
CBD stones

15. Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones

16. 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

17. Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones

18. 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

19. 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

21. 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

22. Outline
Standard treatment of CBD stones
Define Difficult Bile duct stone
Factors associated with difficult CBD stones
Treatment strategies of difficult CBD stones

23. Principle for treatment
Difficult biliary stone
Decrease stone size
Larger CBD orifice

24. Principle for treatment
Difficult biliary stone
Decrease stone size
Larger CBD orifice

25. Endoscopic Management of
Large Bile Duct Stones
Mechanical lithotripsy
Intraductal shockwave lithotripsy
Electrohydraulic
Laser
Extracorporeal shockwave lithotripsy
Dissolution
MTBE
Monooctanoin
Long term stents

26. Endoscopic Management of
Large Bile Duct Stones
Mechanical lithotripsy
Intraductal shockwave lithotripsy
Electrohydraulic
Laser
Extracorporeal shockwave lithotripsy
Dissolution
MTBE
Monooctanoin
Long term stents

27. Mechanical lithotripsy
Integrated
Salvage

28. 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

31. Soehendra Mechanical Lithotriptor

32. Mechanical lithotripsy- Salvage

33. Principle for treatment
Difficult biliary stone
Decrease stone size
Larger CBD orifice

34. Large Balloon
Dilatation of Sphincter

35. Bile Duct Stones
Failed Mechanical Lithotripsy
ESWL
Percutaneously Surgery
Cholangioscope
- Laser
- EHL
Stent
Dissolve

36. 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

37. Mother-Baby Scope System

38. Spyglass

39. Spyglass
10 Fr catheter
Guidewire
Optical fiber
Direction
dials +
locks
Irrigation port

41. Cholangioscopy and
Stone fragmentation

42. Endoscopic management of
Calculous cholecystitis
Comorbidities
Elderly
Trans papillary GB stenting / drainage
EUS guided cholecystoduodenostomy

43. 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

44. 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

45. 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