Choledocholithiasis

A case presentation with discussion

1. Choledocholithiasis Dr. Shirish Silwal House Officer Dept. of General Surgery & Urology B & B Hospital Pvt. Ltd.

2. Case Mr NBR age 42 yr male admitted from SOPD Acute pain in epigastrium and RUQ for 5 days Pain is constant, dull , non radiating, aggravated by intake of food a/w nausea , with yellowish discoloration of skin and sclera. Passing dark coloured urine and clay coloured stools. No h/o fever, itching . No other co-morbidity and surgical history

3. On examination  General condition >> fair Anaemia (-), Cyanosis (-), Oedema (-)  Jaundice +++  Vitals stable Per Abdominal Finding >>Tenderness and guarding present in right upper quadrant. Bowel sound (+)

4. INVESTIGATION HEMATOLOGY Liver Function Test BIOCHEMICAL TEST WBC 5200 cu.mm Neutrophils 82% ESR 35mm/ Hr westergreen Hb 15.2 gm Platelets 60,000 BT 3min, CT 9min PT 13.8, INR 0.99 Bilirubin T- 14.8mg/dl D- 10.4mg/dl ALT/AST 207 / 207 IU /L ALK P 600 IU/L Urea/Cr 29/0.95 Na/K 133/3.3 Amylase/Lipase 117/218

5. ULTRASONOGRAM HEMATOLOGY Multiple choledocholithiasis with obstructive dilatation of CBD and IHBD. Mucocele of the GB ? Impending acute cholecystitis . Hb 10.3 Platelets 58000, 88000, 22000 PT 13.4 ,INR 0.96 APTT 37sec

6. PREOPERATIVE PERIOD Patient was managed conservatively up to 3 rd DOA. Patient was shifted to POW in 2 nd DOA then to ICU on same day. Antibiotics was stepped up from CEFTRIAXONE AND METRONIDAZOLE>> MAGNEX AND METRONIDAZOLE >>>MEROPENEM AND METRONIDAZOLE. PRP 8 Pints was transfused then 2 packets Concentrated platelets was transfused (PLTS 88000 ) VITALS: BP 130/80, PULSE 100, TEMP 98°F, SPO 2 96% WITH 4L O 2 .

7. INTRAOPERATIVE PERIOD Platelets 8 8 000. OPEN CHOLECYSTECTOMY + ECBD + IOC was done Finding Pre Gangrenous gall bladder containing multiple calculi with sludge and infected bile. Grossly dilated CBD and bilateral hepatic duct containing multiple impacted calculi. Moderate adhesions at the calot’s triangle . liver normal IOC- free flow of dye into bilateral hepatic ducts and duodenum. No filling defect seen .

8. GALL BLADDER STONE CBD STONE

9. POSTOPERATIVE FINDING INVESTIGATION HEMATOLOGY BIOCHEMISTRY LIVER FUNCTION Hb 8.2, 9.9,10.3,9.8 gm Platelets-164000,152000 113000,120,000 WBC 15,400 . UREA 57,33,23 Cr O.80,0.63,0.62 Na/ K+ 138/3.5 BILLIRUBIN T-5.7,10,9.8 D-4, 4.5,8 ALT-108,71,73 AST-114, 90,101 ALK P- 591,145,164

10. 9 th POD T-TUBE Clamp done 11 th POD drain removed, suture all removed and discharge. On 18 th POD liver function test Bilirubin T/D 3.7/2.6 ALT/AST 91/81 ALK P 245 T-tube removed on 22 nd POD

11. Discussion

12. CHOLEDOCHOLITHIASIS Stone in common bile duct . 10 to 18% of patients with stones in the gallbladder I ncidence increases with age . About 20 to 25% of patients above the age of 60 with symptomatic gallstones have stones in the common bile duct as well as in the gallbladder .

13. TYPES OF STONE PRIMARY CBD STONE A/W biliary stasis and infection Brown pigmented SECONDARY CBD STONE Stone migrate from gall bladder cholesterol stones in 75% black pigment stones in 25%

14. Clinical presentation Jaundice ++ White coloured stools Dark urine Scratch marks in body Yellowish discolouration of sclera, nail bed Tender right upper quadrant, Palpable gall bladder +/-

15. In severe condition General appearance toxic Jaundice +++ Vitals: hypotension, febrile, tachycardia Per abdominal finding Tender right upper quadrant with guarding Bowel sound sluggish or absent Charcot’s triad of cholangitis right upper quadrant pain, jaundice, and fever .

16. Common bile duct stones are covered by a bacterial biofilm of adherent quiescent bacteria residing in a hermetic environment. When stones cause obstruction of the ducts, cytokines released by epithelial cells activate these bacteria to the virulent forms . Sepsis is much less likely to occur in the context of malignant obstruction without choledocholithiasis . Maingot's Abdominal Operations

17. Courvoisier's law   In his book “ Casuistisch-statistische Beiträge zur Pathologie und Chirurgie der Gallenwege ” The pathology and surgery of the gallbladder” published in Liepzig in 1890, Ludwig Courvoisier - a swiss surgeon stated that “with obstruction of the common duct by a stone , dilatation is rare. The organ is usually well shrunken . With obstruction from other kinds, on the contrary , distension is the rule. Shrinking occurs in only one twelfth of cases.”

18. If gallbladder is palpable in a jaundiced patient, it is unlikely to be due to gallstones , because stones would have given rise to chronic inflammation and subsequently fibrosis of gallbladder therefore, rendering it incapable of dilatation. Conversely, the causes other than stone (principally tumours ), would result in the distension of gallbladder, felt on abdominal palpation.

19. Investigation Elevation of serum bilirubin , alkaline phosphatase, and transaminases are commonly seen in patients with bile duct stones . Ultrasonography Magnetic resonance cholangiography (MRC) Endoscopic cholangiography Schwartz's Principles of Surgery  

20. Management Primary management High glucose diet Protein restriction IV Broad spectrum antibiotics Vitamin K Lactulose Correction of metabolic and coagulation abnormality

21. Definite Management If an endoscopic cholangiogram reveals stones, sphincterotomy and ductal clearance of the stones is appropriate, followed by a laparoscopic cholecystectomy . O pen common bile duct exploration is an option if the endoscopic method has already been tried or is, for some reason, not feasible. If a choledochotomy is performed, a T tube is left in place . Stones impacted in the ampulla may be difficult for both endoscopic ductal clearance as well as common bile duct exploration (open or laparoscopic). In these cases the common bile duct is usually quite dilated (about 2 cm in diameter). A choledochoduodenostomy or a Roux-en-Y choledochojejunostomy may be the best option under this circumstance . Schwartz's Principles of Surgery  

22. Surgical versus endoscopic treatment of bile duct stones Open bile duct surgery seems superior to ERCP in achieving common bile duct stone clearance based on the evidence available from the early endoscopy era. There is no significant difference in the mortality and morbidity between laparoscopic bile duct clearance and the endoscopic options. There is no significant reduction in the number of retained stones and failure rates in the laparoscopy groups compared with the pre-operative and intra-operative ERCP groups. There is no significant difference in the mortality, morbidity, retained stones, and failure rates between the single-stage laparoscopic bile duct clearance and two-stage endoscopic management. More randomised clinical trials without risks of systematic and random errors are necessary to confirm these findings . Cochrane Database Syst Rev. 2013 Sep 3;9:CD003327. doi: 10.1002/14651858.CD003327.pub3.

23. Primary closure Primary closure of the CBD after exploration can be done only if certain criteria such as the following are satisfied: Patent ampulla of Vater Complete removal of all intraductal calculi Absence of pancreatic pathology Meticulous suture of the duct Indian J Surg (July–August 2012) 74(4):323–324

24. World Journal of Surgery January 2012, Volume 36, Issue 1, pp 164-170 Primary Closure Following Laparoscopic Common Bile Duct Exploration Combined with Intraoperative Cholangiography and Choledochoscopy Background Laparoscopic common bile duct exploration (LCBDE) has become one of the main options for treating choledocholithiasis associated with cholelithiasis . Our objective was to assess the short-term outcomes of patients undergoing laparoscopic primary closure of the common bile duct (CBD) compared with laparoscopic choledochotomy plus T-tube drainage. Methods We retrospectively studied 137 patients undergoing primary closure following LCBDE (group A) compared with 102 cases with laparoscopic choledochotomy plus T-tube drainage (group B) between January 2007 and January 2010. Intraoperative cholangiography (IOC) and choledochoscopy were performed in all patients. Results Three patients in group A (2.2%) were converted to open surgery and two (2.0%) in group B because of serious adherence. According to routine IOC, unexpected CBD stones were found in 16 cases (6.8%). The duration of the operation in group A was shorter than in group B (92.4 ± 15.2 vs. 125.7± 32.6 min, P  < 0.05), as was length of postoperative stay (3.1± 2.4 vs. 5.7± 4.3 days, P  < 0.05). Postoperative bile leakage occurred in six patients (4.5%) in group A and four cases (4.0%) in group B; all of the patients recovered after simple drainage without reoperation. Bile peritonitis was seen in one case after T-tube removal. The median follow-up was 26 months. There were no recurrences. Conclusions Laparoscopic primary closure of the CBD is safe and successful for the management of CBD stones. Application of IOC and choledochoscopy to ensure clearance of the CBD and careful suturing are essential for primary closure.  

25. T-tube drainage versus primary closure after open commonbile duct exploration T-tube drainage appeared to result in significantly longer operating time and hospital stay compared with primary closure without any apparent evidence of benefit on clinically important outcomes after open common bile duct exploration. Based on the currently available evidence, there is no justification for the routine use of T-tube drainage after open common bile duct exploration in patients with common bile duct stones. T-tube drainage should not be used outside well designed randomised clinical trials. More randomised trials comparing the effects of T-tube drainage versus primary closure after open common bile duct exploration may be needed. Such trials should be conducted with low risk of bias and assessing the long-term beneficial and harmful effects of T-tube drainage, including long -term complications such as bile stricture and recurrence of common bile duct stones. T-tube drainage versus primary closure after open common bile duct exploration (Review) Copyright © 2013 The Cochrane Collaboration. Published by John Wiley & Sons, Ltd.

26. INDICATION OF CHOLEDOCHODUODENOSTOMY Dilated common duct > 15mm with stones   Multiple common bile duct stones   Intra hepatic calculi   Primary common bile duct stones   Residual / Recurrent stones Stone impacted in the ampulla of Vater Side to side CDD is an easy, effective and definitive method of decompression, especially when there are multiple stones in a dilated CBD Kathmandu University Medical Journal (2003) Vol. 2, No. 3, Issue7, 193 - 197

27. N Am J Med Sci. 2013 Apr;5(4):288-92. doi : 10.4103/1947-2714.110438. Open Choldecho-Enterostomy for Common Bile Duct Stones: Is it Out of Date in Laparo -Endoscopic Era? Abdelmajid K , Houssem H , Rafik G , Jarrar MS , Fehmi H . Source Department of General Surgery, Professor Rached Letaief at Farhat Hached Hospital, Sousse, Tunisia. Abstract BACKGROUND: Nowadays, biliary-enteric drainage (BED) is regarded as a last resort or obsolete therapeutic method for common bile duct stone (CBDS) not only because of advances in minimally invasive therapeutic modalities but also due to fears of higher morbidity, cholangitis, and "sump" syndrome. AIM: The present study aimed at evaluating the outcome of this procedure for choledocholithiasis . MATERIALS AND METHODS: It is a retrospective review of 51 patients who underwent open choledochoenterostomy for CBDS between January 2005 and December 2009. RESULTS: About 40 women (78%) and 11 men underwent open BED (mean age 72 years). Indications were elderly patients (90%), multiple stones (54.9%) and unextractable calculi (15.4%). We performed 49 (96%) side to side choledochoduodenostomies , one end to side choledochoduodenostomy (CDS) and one end to side hepaticojejunostomy . The mortality rate was 3.9%. Overall morbidity was 12% with no biliary leakage. With a decline of 1-6 years, neither sump syndrome nor cholangiocarcinoma occurred. Conclusion Side -to-side CDS is a safe and highly effective therapeutic measure, even when performed on ducts less than 15 mm wide, provided a few technical requirements are respected. Patients experiencing relapsing cholangitis after Biliary enteric drainage should be closely monitored for the late development of biliary tract malignancies . N Am J Med Sci. 2013 Apr;5(4):288-92.

28. INDICATION OF HEPATOJEJUNOSTOMY frequently with the advent of laparoscopic cholecystectomy and its higher rate of bile duct injuries. biliary fibrosis produced by chronic pancreatitis penetrating trauma of the porta hepatis previous bilioenteric operations with subsequent   stricture formation choledochal cyst resections I atrogenic biliary trauma ( gastrectomy , pancreatic and hepatic resections, portal decompressive procedures, and liver transplantation)  

29. Malignant conditions cholangiocarcinomas and carcinomas of the gallbladder infiltrating the common bile duct  (CBD) or hepatic ducts may also be indications for performing HJ as the final step of the resective procedure or as a palliative attempt to relieve jaundice. From the Department of Surgery, Mayo Clinic, Rochester, MN.

30. Conclusion Choledocholithiasis occurs in about 10 to 18% of patients with cholelithiasis . Although USG is not the best but it is the commonest first line investigation. Endoscopic cholangiography is the gold standard for diagnosing common bile duct stones Surgical Procedure depends upon expertise and experienced of surgeon, patient condition and facilities available. Minimal invasive procedure encouraged for less postoperative co-morbidity and mortality .

31. Thank you