Choledocholithiasis- Management

CBD stone management and its complication during management

1. Management of common bile duct stone and its complications Presenter: Dr Lilamani Rajthala MS Resident General Surgery

2. Relevant Anatomy

3. Introduction: Choledocholithiasis Found in 6 to 12 % of patients with cholelithiasis. Increases with age. Above age of 60, incidence is 20-25% of patient with symptomatic gall stones. Primary stones: Form in bile duct, usually brown pigment type. Associated with biliary stasis and infection due to biliary stricture, papillary stenosis , tumor, or other stones. Usually <1 cm, Brownish yellow, soft and mushy. Secondary to bacterial infection caused by bile stasis. E coli secrete   β -glucuronidase cleaves bilirubin glucuronide to unconjugated bilirubin. Precipitates with calcium with dead bacterial cells and form soft stone in bile ducts.

4. Introduction: Choledocholithiasis Secondary stone: Vast majority form in gall bladder and migrate down to CBD. Usually cholesterol stones, variable amount of bile pigment and calcium, always >70% cholesterol. Usually multiple, variable size, hard, faceted, irregular, mulberry shaped or soft. Mostly radiolucent, <10% radiopaque. Supersaturation of bile with cholesterol, almost always due to hypersecretion.

5. Clinical manifestation Silent and often discovered incidentally. Epigastric or right upper quadrant pain. Intermittent pain and transient jaundice: Temporarily impaction at ampulla. Severe progressive jaundice. Complete or incomplete obstruction leading to cholangitis or gallstone pancreatitis.

6. Investigation Blood investigation: Liver function test: Elevated serum bilirubin, alkaline phosphatase and transaminase. Normal in one third cases: do not preclude further investigation if clinical suspicion is high. Complete blood count: Neutrophilia if cholangitis. Deranged coagulation profile: Obstructive jaundice or liver parenchymal disease.

7. Investigation Ultrasonography: Visualization of stone in CBD as well as documentation of GB stone if present. Stone in distal CBD: bowel gas can preclude their demonstration. Dilated CBD> 8mm. Sensitivity and Specificity: 73% and 91% respectively.

8. Investigation MRCP: Excellent anatomical details of biliary tree. CBD stone will appear as well defined dark filling defects within CBD. Sensitivity and Specificity of 95% and 89% respectively in detecting stones >5mm. [Earl Williams et al, Updated guideline on the management of common bile duct stones, Gut 2017]

9. Investigation EUS: Positioned in duodenal bulb. Uses high frequency sound waves to image the bile duct. CBD appears hyperechoic foci with characteristic acoustic shadowing. Frequency of 7.5 and 12 Mhz. Sensitivity of 94% and specificity of 95%. Sensitivity and specificity independent of the size of deposits. However depends on experience of performing surgeon. Suggests replacement of diagnostic ERCP with EUS due to possible complication. [ Jasoslaw Leszczyszyn , J Ultrason . 2014 Jun.]

10. Investigation ERCP: Most studies concluded that routine ERCP not indicated. Safe, highly accurate and therapeutic potential. Study bile duct anatomy, identify abnormalities of bile duct, rule out other differentials ( eg. Malignancy) Indications: Elevated LFT. Dilated CBD >8mm. CBD stone in USG examination. Coexisting pancreatitis. History of acute pancreatitis and jaundice. [Laszlo Lakatos et al, World Journal of Gastroenterology. 2004 Dec]

11. Investigation Contraindication: Absolute: medical condition precluding sedation and general anesthesia. Relative: Anatomical condition that would impede endoscope access. Clinically significant coagulopathy

12. Investigation CT scan: Routinely not used for the purpose of detecting CBD stone. Important role in identification of malignant obstruction. CT cholangiography with excreted biliary contrast can achieve sensitivity(69-87%) and specificity ( 68-96%) for detecting CBD stone. Accuracy decreases with decrease in size of calculi and similar density to bile. [Earl Williams et al, Updated guideline on the management of common bile duct stones, Gut 2017]

13. Questions and Answers?

14. Management Endoscopic Management. Laparoscopic CBD Exploration. Open CBD Exploration. Percutaneous radiological stone extraction. Stenting alone. Dissolution Therapy.

15. Endoscopic management Minimally invasive technique and effective treatment. ERCP: Gold standard for diagnosis CBD stone. Advantage of therapeutic option. Diagnostic cholangiography in >90% cases with <5% morbidity (cholangitis and pancreatitis) Recommended that patient diagnosed with CBD stone are offered stone extraction if possible.

16. Endoscopic management Overall follow up to 4 years, 25.3% of patients developed unfavorable outcomes: Pancreatitis, cholangitis, obstruction of bile duct. Endoscopic sphincterotomy with stone extraction. Does not eliminate the risk of recurrent biliary stone disease. 50% have recurrent symptoms if not treated with cholecystectomy. Failure: large stones, intrahepatic stones, multiple stones, altered gastric and duodenal anatomy, impacted stones and duodenal diverticula.

17. Endoscopic papillary balloon dilatation Adjuvant to biliary sphincterotomy, facilitate removal of large CBD stone. EPBD alone increases the risk of PEP but considered in selected cases with uncorrected coagulopathy or biliary access. 8 mm diameter balloon is recommended in EPBD alone. EPBD with sphincterotomy: Reduces need of mechanical lithotripsy. 10 mm balloon used- avoid dilatation beyond the diameter of bile duct above.

18. Endoscopic balloon dilatation Contraindication of EPBD without sphincterotomy : Biliary stricture or malignancy Previous biliary surgery Cholangitis Pancreatitis Prior access papillotomy Large CBD stone (>12mm)

19. Access papillotomy Adjunct to endoscopic biliary cannulation in cases where access is difficult. Precut or needle knife papillotomy. Risk of pancreatitis and perforation.

20. Cholangioscopy : Allows endoscopic visualization within biliary tree and offer lithotripsy under direct vision using electrohydraulic or laser energy. Earlier: “mother and baby” system- two operators. Newly, Single operator cholangioscope with fiber optic visualization system passed through the duodenoscope. Electrohydraulic lithotripsy and laser lithotripsy results in high stone clearance (73-97%). Cholangitis ( up to 9%)-prophylactic antibiotics.

21. Anesthesia supported ERCP Tolerability and success is higher if performed with propofol sedation or general anesthesia. Propofol assisted ERCP: considered for complex cases like intrahepatic ductal stones and cholangioscopy assisted lithotripsy. GA with Intubation: Morbid obesity, airway/ventilation problem.

22. Complication: Post ERCP pancreatitis Well recognized complication. Criteria: Clinical picture of pancreatitis, onset with 24 hour of procedure. Persistent amylasemia (over 24 hour) over 3 times the normal range, Hospitalization for at least 2 days. Frequency varies considerably with 2-5% most commonly reported. Emphasizes the necessity of reserving ERCP as therapeutic procedure. [A lorgulescu , J Med Life. 2013 Mar 15]

23. Post ERCP pancreatitis Pathophysiology: Mechanical injury of pancreatic sphincter or main pancreatic duct. Pancreatic sphincter edema due to sphincterotomy. Prolonged sphincter spasm. Excessive injection of contrast. Extrinsic compression of main pancreatic duct through distal CBD stone. Bacterial contamination.

24. Post ERCP pancreatitis Prevention: Prophylactic NSAIDs ( 100mg Indomethacin or diclofenac) Short term pancreatic duct stenting in high risk cases. In increased risk due to patient factors (young age , female, suspected sphincter of Oddi dysfunction) or procedure relation (repeated pancreatic duct cannulation) Insertion of 5 F pancreatic stent, optimum duration hours to days. Confirm spontaneous migration via abdominal X ray. When spontaneous migration doesn’t occur: Endoscopic removal.

25. Coagulopathy prior to Sphincterotomy. Patients should have CBS and PT/INR performed. Abnormal clotting due to biliary obstruction and liver parenchymal disease. May cause GI Hemorrhage. For endoscopic stenting alone, warfarin in continued and other oral anticoagulants omitted on morning of procedure. For sphincterotomy, discontinuation of oral anticoagulation 2-5 days prior intervention. Bridging therapy is reserved for high risk cases.

26. Laparoscopic CBD exploration: Intra operative cholangiography to identify choledocholithiasis. At the time of cholecystectomy. Approach: Transcystic or choledochotomy. Transcystic approach: Cystic duct dilated using Seldinger technique. Flexible choledochoscope is passed and advanced to CBD. Wire basket is passed to ensnare the stone and withdrawn. Contraindication: stones in common hepatic duct, small friable cystic duct, multiple ( >8 )stones in CBD, large stone (>1 cm).

27. Laparoscopic CBD exploration: Choledochotomy : Longitudinal incision on CBD. Incision size at least as large as largest stone. Choledochoscope inserted to distal duct and stone extracted. T tube placed an bile duct closed. Completion cholangiography. Contraindication: Small caliber bile duct (<6mm).

28. Laparoscopic CBD exploration: Success rate: 75% to 95%. Duct clearance up to 100% with the availability of intraductal piezoelectric or Laser lithotripsy. Complications: Predominantly related to choledochotomy ( bile duct leakage) and T tube use (bile leakage, tube displacement). T tube inserted to avoid risk of bile leakage. But increased morbidity: discomfort for 10-14 days, inadvertent early removal resulting leakage, peritonitis and reoperation, need of postoperative T tube cholangiogram.

29. T tube drainage After CBD exploration with supraduodenal choledochotomy. Short transverse part (20cm) and long longitudinal part (60cm) Clinical use significantly decreased due to less invasive alternative. Indication: To drain CBD after choledochotomy. Repairing limited injury of CBD over T tube. CBD drainage when ERCP and PTC fail to clear CBD obstruction.

30. Intraoperative cholangiogram Intraoperative cholangiography done selectively during cholecystectomy Indication: Any suspicion of cholelithiasis Pain at the time of operation Abnormal LFT Anomalous or confusing biliary anatomy Inability to perform postoperative ERCP like Roux-en-Y gastric bypass. Dilated biliary tree

31. Questions and Answers?

32. Open CBD exploration: Frequency has decreased. Carries low morbidity (8-15%) and mortality (1-2%). Indication: when concomitant biliary drainage is required. Midline or right upper quadrant incision. Kocher maneuver to expose distal CBD. Gentle palpation to assess offending stone, may be milked backward. Choledochotomy at supra duodenal bile duct.

33. Open CBD exploration: Flushing with a soft rubber catheter. Balloon catheter with wire basket under fluoroscopic guidance. Flexible choledochoscopes . T tube placement and cholangiogram before closure.

34. Open CBD exploration: Drainage procedure: Indications: dilated bile ducts, multiple distal impacted stones, a distal duct stricture with stones, intrahepatic stones, or primary bile duct stones. For dilated biliary tree: Choledochoenterostomy . Includes Choledochoduodenostomy or Roux-en-Y choledocho jejunostomy.

35. Choledochoduodenostomy Indication: Dilated CBD >15 mm. Multiple CBD stones Intrahepatic calculi. Primary CBD stone. Residual/ recurrent stones. Stone impacted in ampulla of Vater . Papillary stenosis.

36. Sump syndrome: Bile duct distal to anastomosis does not drain well and may collect debris predisposing to cholangitis or biliary pancreatitis. Roux-en-Y choledochojejunostomy : 60-cm limb of jejunum for drainage. No risk of Sump syndrome but prevents future endoscopic evaluation of biliary tree.

37. Transduodenal sphincterotomy Indication: Several stones in a nondilated biliary tree or impacted stone at ampulla that cannot be removed through choledochotomy. Procedure: Kocher maneuver. Longitudinal duodenotomy on lateral wall. Identification of ampulla and incision at 11 o’clock. 5 o ’clock avoided-entry of pancreatic duct. Duodenal mucosa sewn to the bile duct mucosa. 1.5 cm sphincterotomy is adequate. Closure of longitudinal duodenotomy in transverse fashion.

38. Stenting as treatment of CBD stone As sole treatment in cases with limited life expectancy or prohibitive surgical risk. Ensure adequate drainage if CBD stones cannot be retrieved. Over a mean follow-up period of 14 months, 36% cholangitis rate in patients who had stents changed on demand with an associated mortality of 8%. Patients who had stents changed electively at three monthly intervals had an 8% cholangitis rate and 2% mortality. Short term use followed by further ERCP or surgery.

39. Stenting as treatment of CBD stone Covered self expanding metal stents (SEMS) can be considered alternative to plastic stents to drain bile ducts. Uncertainties over how long the stents should be left in place and cost benefit ratio. ESGE recommend a plastic stent should be removed or exchanged within 3 – 6 months to avoid infectious complication.

40. Difficult ductal stone Diameter>1.5 cm, unusual shape ( barrel shaped), location (intrahepatic or cystic duct), anatomical difficult ( narrow bile duct distal to stone, sigmoid shaped CBD, stone impaction, shorter length of distal CBD, acute distal CBD angulation <135 degree) Mechanical lithotripsy, EPBD with prior sphincterotomy and cholangioscopy or extracorporeal shock wave lithotripsy fail to remove stones. Percutaneous radiological stone extraction and open duct exploration.

41. Percutaneous radiological stone extraction Achieved by either a transhepatic or transcholecystic biliary fistula. Balloon dilation of the biliary sphincter, which allows stones to be pushed in an antegrade fashion into the duodenum. Larger calculi will require lithotripsy (either mechanical, electrohydraulic or laser)

42. Extracorporeal Shock wave Lithotripsy High pressure electrohydraulic or electromagnetic energy. Delivered to the designated target point to fragment stone. Naso biliary drain to allow fluoroscopic identification and targeting CBD stone. Adverse effect: Pain, local hematoma, cardiac arrythmias, biliary obstruction, hemobilia and hematuria. Contraindication: Portal vein thrombosis and varices in umbilical plexus. Uncommonly used and not a first line treatment.

43. Dissolution therapy. Ursodeoxycholic acid with or without turpentine preparation has been suggested. But two RCTs have investigated and revealed no significant difference in reducing the rate of stone recurrence. Hence UDCA or other agents are not recommended.

44. In Specific Clinical settings: With or without gall bladder: Cholecystectomy is recommended in all patients with CBD stones. Minimally invasive nature of ERCP -primary form of treatment in post cholecystectomy status. Cholangitis: Urgent biliary decompression with endoscopic CBD stone extraction and/or biliary stenting. If not possible: Percutaneous radiological drainage.

45. Acute biliary pancreatitis: With associated cholangitis or biliary obstruction: Biliary sphincterotomy and endoscopic stone extraction within 72 hours of presentation. Early laparoscopic cholecystectomy offered at same setting.

46. Recurrent CBD stones Risk factors Multiple common bile duct stones, biliary dilatation> 13 mm Prior open cholecystectomy Prior gallstone lithotripsy Hepatolithiasis Biliary stasis due to periampullary diverticula, papillary stenosis, biliary stricture or tumor and angulation of the common bile duct.

47. Recurrent CBD stones Management: Repeat endoscopic intervention. Surgical options: Biliary Drainage: Choledochoduodenostomy Hepaticojejunostomy Transduodenal sphinteroplasty

48. Altered gastric and duodenal anatomy Balloon assisted ERCP or Endoscopic ultrasound directed transgastric ERCP- require advanced endoscopic expertise. Billroth II gastrectomy: Side viewing duodenoscope facilitates cannulation and subsequent therapy. Using sphincterotomes modified to alter the orientation of the cutting wire or by using conventional sphincterotomes that rotates. Biliary sphincterotomy using a needle knife, with a straight plastic stent as a guide.

49. Roux-en-Y gastric bypass:

50. Take home message All patients with CBD stone is offered stone extraction. USG and LFT may be normal in case of CBD stones. MRCP and EUS are highly accurate test in identifying CBD stone. Tolerability and success is higher in ERCP with sedation or anesthesia. Laparoscopic duct exploration and ERCP with sphincterotomy, mechanical lithotripsy or cholangioscopy are highly successful. When endoscopic cannulation is not possible, percutaneous or EUS guided procedure can facilitate. Percutaneous radiological stone extraction and open duct exploration are reserved for small number of cases.

51. References Earl Williams et al, Updated guideline on the management of common bile duct stones, Gut 2017 . Gianpiero Manes et al, Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline, Endoscopy 2019. Sabiston Textbook of Surgery, The biological basis of modern surgical practice, 20 th Edition. Schwartz’s Principles of Surgery, Ninth Edition.