Common Bile Duct Stones: Leave Them Get Them or Refer Them

1. Common Bile Duct Stones:Common Bile Duct Stones:

Joel A. Ricci, MD
George Ferzli, MD, FACS
Leave them Leave them
get them…get them…
or refer themor refer them

2. ObjectivesObjectives
•Pre-operative identification of risk factors associated with
choledocholithiasis
•Learn different approaches in managing CBD stones
•Intra-operative decision making according to patient’s
circumstances
•Recognize complications associated with different approaches

3. •1882 Langenbuch – Cholecystectomy
•1889 Abbe – Choledochotomy
•1890 Ludwig Courvoisier – CBD exploration
•1932 Mirizzi – Intraop cholangiography
•1941 McIver – Rigid choledochoscopy
•1957 Wild – Endoscopic ultrasound
•1968 McCune – ERCP
•1986 Muhe – LAP cholecystectomy
•1991 Wallner – MRCP

HistoryHistory

4. EtiologyEtiology
Point of origin:
• Secondary (gallbladder)
• Primary (de novo within biliary tract)
• Primary CBD stones:
• South-east asian populations
• Associated with stasis and infection
• Brown pigment type
• Soft and easy to crumble
Biliary stasis:
• Biliary stricture
• Papillary stenosis
• Sphincter of Oddi dysfunction
Positive biliary cultures:
• Stasis
• Bacterial glucoronidases
• Deconjugation of bilirubin diglucuronide & precipitation of bilirubin as its
calcium salt

5. • Blood tests
• Transabdominal ultrasound
• ERCP
• Endoscopic ultrasound
• MRCP
Preoperative SuspicionPreoperative Suspicion

6. * 600,000 cholecystectomies annually in the U.S.,
8%-20% have CBD stones, no consensus on
optimal management.
** “No single clinical indicator is completely accurate
in predicting CBD stones prior to cholecystectomy.”
* Liu, TH et al. Ann Surg 234(1), July, 2001.
**Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996

7. Lezoche, E. Surg Endosc. 9(10), 1995
LIVER FUNCTION TESTS INCIDENCE OF CBD
STONES
NORMAL 4%
One Abnormal Value
20%
Three Abnormal Values
50%
Liver Function TestsLiver Function Tests

8. Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996
INDICATORINDICATOR SENSITIVITYSENSITIVITY SPECIFICITYSPECIFICITY
CBDS on USCBDS on US 0.380.38 1.001.00
CholangitisCholangitis 0.110.11 0.990.99
Preop jaundicePreop jaundice 0.360.36 0.970.97
Dilated CBD on USDilated CBD on US 0.420.42 0.960.96
AmylaseAmylase 0.110.11 0.950.95
PancreatitisPancreatitis 0.100.10 0.950.95
JaundiceJaundice 0.390.39 0.920.92
BilirubinBilirubin 0.690.69 0.880.88
Alk phosAlk phos 0.570.57 0.860.86
CholecystitisCholecystitis 0.500.50 0.760.76

9. Liu TH et al: Patient evaluation and management with selective use of magnetic
resonance cholangiography and endoscopic retrograde cholangio pancreatography
before laparoscopic cholecystectomy. Ann Surg 234: 33-40, 2001

10. Dilated
CBD
Transabdominal UltrasoundTransabdominal Ultrasound
Test of choice for detecting cholelithiasis and common bile
duct dilatation
Low sensitivity (30%-50%) for common bile duct stones
Eisen, GM. Gastrointestinal Endoscopy. 53(7), 2001.

11. SENSITIVITY 75%-100%
SPECIFICITY 77%-100%
Rosch, TJ Gastro Surg. 5(3), 2001
Endoscopic UltrasoundEndoscopic Ultrasound

12. STUDY NSensitivitySpecificity
Edmundowicz (1992) 20 75% 100%
Palazzo (1995) 422 95% 98%
Prat (1996) 119 93% 97%
Sugiyama (1997) 142 96% 100%
Montariol (1998) 240 85% 93%
Polkowski (1999) 52 91% 100%
Materne (2000) 50 92% 95%
Lachter (2000) 50 97% 77%
Endoscopic UltrasoundEndoscopic Ultrasound

13. MRCPMRCP
•Sensitivity: 90%
•Specificity: 100%
•High cost
•Limited availability
•Non therapeutic

14. •Diagnostic and therapeutic
•Invasive study
•Success: 99%
•Mortality: 1%
•Morbidity: 6%
•Long term complications?
Cotton, 1996
ERCPERCP

15. ERCPERCP
Diagnostic and therapeutic
Endoscope into 2
nd
portion of duodenum
Papilla visualized at 12 or 1 o’clock
•Small nub across semicircular folds
•Soft reticulated area at tip = papillary orifice
Cannulation of orifice
•Fluoroscopy
•CBD orifice at 11 o’clock
•Pancreatic duct orifice at 1 to 2 o’clock

16. ERCPERCP
CBD cannulation via guidewire
Sphincterotomy
•Electrosurgical division of papilla
Stone retrieval:
•Balloon sweep
•Basket
•Crushing technique
Strictures:
•Cytologic brushings
•Balloon dilation
•Stent placement

17. ERCPERCP
Complications
• Acinarization or rupture of small ductules
• Pancreatitis: contrast extravasation into duct
• Cholangitis: contrast into proximal biliary tree
• Duodenal perforation:
 Retroperitoneal or free intraperitoneal air ® Emergency surgery
• Bleeding:
Epinephrine
Electrocoagulation
Balloon tamponade
Arteriographicembolization of GDA

18. Indicated for patients with
pancreatitis and concomitant
cholangitis.
No indication for routine
ERCP in patients with
gallstone pancreatitis who will
undergo cholecystectomy.
SSAT, AGE, ASGE Concensus Panel. J Gastroint Surg. 5(3) 2001.
ERCPERCP

19. ERCPERCP
Prospective randomized trial on pts w/ resolving gallstones pancreatitis
•34 pts had Lap chole w/ Intra-op cholangiogram
•29 pts had preop MRCP
If MRCP negative ® Lap chole w/ IOC
If MRCP positive ® ERCP followed by Lap chole
MRCP prediction of CBD stones
•Sensitivity: 100%
•Specificity: 91%
•Positive predictive value: 50%
•Negative predictive value: 100%
•Accuracy: 92%
Hallal AH, et al. MRCP accurately detects common bile duct stones in
resolving gallstones pancreatitis. JACS 2005;200(6):869-875
Conclusion: Patients with resolving gallstones pancreatitis and a negative
MRCP do not need pre-op ERCP or Intra-op cholangiogram

20. •Intraoperative cholangiogram
•Laparoscopic ultrasound
•Indocyanine green injection
Intraoperative SuspicionIntraoperative Suspicion

21. STATIC DYNAMICfilling defect
Laparoscopic CholangiogramLaparoscopic Cholangiogram

22. Advantages
•Identification of biliary
anatomy
•Recognition of
aberrant anatomy
•Early recognition of
CBD injury
•Identification of CBD
stones
Disadvantages
•Increased OR time
•Increased cost
•Requires advanced
technical skills
Laparoscopic CholangiogramLaparoscopic Cholangiogram

23. •Less time consuming (<5 mn)
•Better quality and higher
resolution
•Higher success rate (99%)
•Possibility of interaction with
the findings
•Required for transcystic
exploration of CBD
•Limited availability
Cuschieri 1994
CholangiogramCholangiogram
DynamicDynamic

24. •Time consuming (>16 min)
•Film often inadequate
•Lower success rate (47%)
•Visualization of anatomy
more difficult
•Difficulty in differentiation
between stones and air
bubbles
CholangiogramCholangiogram
StaticStatic

25. Cost effective analysis of intra-op Cost effective analysis of intra-op
cholangiogramcholangiogram
Decision analytic models for cost & benefit
$100 more per routine IOC with every Lap chole
Routine IOC would prevent 2.5 deaths per every 10,000
pts
$390,000 cost per life saved
$87,143 cost per CBD injury avoided w/ IOC
Flum DR, Flowers C, Veenstra DL. A Cost-Effectiveness Analysis of
Intraoperative Cholangiography in the Prevention of Bile Duct Injury During
Laparoscopic Cholecystectomy. JACS 2003;193(3):272-280

26. Current trends regarding intra-op Current trends regarding intra-op
cholangiogramcholangiogram
Survey performed among 4,100 general surgeons
44% responders
27% defined themselves as routine IOC users
91% reported IOC use in >75% of Lap chole
Academic surgeons less prone to use (15% vs 30%)
Selective users more often low volume surgeons
Routine users more often high volume surgeons
“Surgeons at greatest risk for causing common bile duct injury
(inexperienced, low-volume surgeons) and those who have the
greatest opportunity to train others are less likely to use IOC
routinely. These represent target groups for quality-improvement
intervention aimed at broader IOC use”
Massarweh NN, Flum DR, et al. Surgeon Knowledge, Behavior, and Opinions
Regarding Intraoperative Cholangiography. JACS 2008;207(6):821-830

27. Laparoscopic UltrasoundLaparoscopic Ultrasound

28. Advantages:
•Not time consuming (mean 8
min) (Santambrogio 1995)
•Safe (Jakimowicz 1993)
•Can be easily repeated at
any stage of the operation
(Rothlin 1994)
•High success rate (~90%)
(Santambrogio 1995)
•High sensitivity (90%)and
specificity (96%) (Oberlin
1994)
Laparoscopic UltrasoundLaparoscopic Ultrasound
Disadvantages
• Failure to recognize biliary injuries
(Santambrogio 1995)
• Increased cost
• Requires surgeon ability in
performing ultrasound
(Stiegman 1994)
• Inadequate examination of the distal
CBD (Santambrogio 1995)
• Low resolution for anatomical details
(Pietrabissa 1995)

29. Laparoscopic US as a good alternative to Laparoscopic US as a good alternative to
intraoperative cholangiography (IOC)duringintraoperative cholangiography (IOC)during
laparoscopic cholecystectomy:results of laparoscopic cholecystectomy:results of
prospective study.prospective study.
685 IOC (-35 cannot canulate cystic duct ) , 269 LUS (-2 steatosis)
IOC detected 4.5% CBDS; LUS 6%
IOC sensitivity 96.9%, specificity 99.2%
LUS sensitivity 100%,specificity 99.6%
Results:
In this prospective study, LUS has been certainly as
effective as IOC as a primary imaging technique for bile
duct. It permitted to detect CBDS with a high specificity
and sensitivity, and was not followed by an increase in
CBDI.
Hublet A et al Laparoscopic US as a good alternative to intraoperative
cholangiography during lap chole: results of prospective study ActaChir Belg.
2009 May-Jun Belgique.

30. Assessment of CBD using laparoscopic US Assessment of CBD using laparoscopic US
during laparoscopic cholecystectomyduring laparoscopic cholecystectomy
115 consecutive patients, LUS successful in112.
Low risk 7%; Intermediate 36.4%; High risk 78.9%.
With increasing experience, LUS can become the
routine method for evaluating the bile duct during
LC. A more aggressive preoperative evaluation of
CBD is mandated in the intermediate and high risk
groups of patients suspected of having CBD stones.
YAO CC et al Assessment of common bile duct using laparoscopic US
during laparoscopic cholecystectomy Surg Laparosc Endosc Percut Tech
2009 Aug Taiwan.

31. Intraoperative cholangiography in combination Intraoperative cholangiography in combination
with laparoscopic ultrasonography for the with laparoscopic ultrasonography for the
detectection of occult choledocholithiasisdetectection of occult choledocholithiasis
103 patients IOC+LUS. Physicians team blinded.
Success rate : IOC 91.3%; LUS 100%
Time required for LUS was shorter.
The sensitivity of IOC combined with LUS was 92.9% which was
greater than of IOC and LUS taken separately.
LUS is usually performed in case where IOC has failed or is
contraindicated. The combination of both methods maximizes
intraoperative detection of occult CBD stones and should at least
be recommended as two complementary methods.
LI JW et al Intraoperativecholangiogram in combination with laparoscopic us
for the detection of occult choledocholithiasis Med SciMonit. 2009 Sept
China

32. Indocyanine Green (ICG) Injection:Indocyanine Green (ICG) Injection:
Shows the confluence between right and left hepatic
ducts during hepatectomy
Enables identification of the cystic duct and CBD
from before dissection of Calot’s triangle during
cholecystectomy
Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using
Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;
208(1):e1-e4

33. Indocyanine Green Injection (ICG)Indocyanine Green Injection (ICG)
AdvantagesAdvantages
•No need for dissection of Calot’s triangle
•No need for insertion of trans-cystic tube
•No exposure to radiation
•No space-occupying C-arm machine required
•Simple and convenient procedure
•Allergic reactions
Ishizawa T, et al. Intraoperative Fluorescent Cholangiography Using
Indocyanine Green: A Biliary Road Map for Safe Surgery. JACS 2009;208(1):
e1-e4

34. Intra-operative Decision MakingIntra-operative Decision Making
•Convert to open?
•Laparoscopic transcystic common bile duct exploration?
•Laparoscopic cholechotomy?
•Defer to post-op management?
•Open or laparoscopic biliary bypass?
•Transduodenal papillotomy?
•Combined laparoscopy + ERCP?

35. Factor Transcystic Choledochotomy
One stone + +
Multiple stones + +
Stones < 6mm + +
Stones > 6mm - +
Intra-hepatic stones - +
Cystic duct < 4mm - +
Cystic duct > 4mm + +
CBD < 6mm + -
CBD > 6mm + +
CD entrance: lateral + +
Entrance: posterior - +
Entrance: distal - +
Mildly inflamed + +
Markedly inflamed + -
Suturing: poor + -
Suturing: good + +
Factors influencing approach to the common bile ductFactors influencing approach to the common bile duct

36. Transcystic:
•Stone < 6 mm
•Cystic duct > 4 mm
•CBD < 6 mm
•Lateral entrance of cystic
duct
•Severe or mild
inflammation
•Poor suturing ability
1998, Petelin
Laparoscopic CBD ExplorationLaparoscopic CBD Exploration
Transductal:
•Stone > 6 mm
•Cystic duct < 4 mm
•CBD > 6 mm
•Posterior or distal entrance of
cystic duct
•Mild inflammation
•Good suturing ability

37. Fogarty
Balloon
dilatation
Ampulla
Basket
Irrigation
+ Glucagon
Fluoroscopy
Transampullary
Guide-wire
Endos. Guided
sphincterotomy
Basket
Choledochoscopy
balloon dilatation
Cystic duct
Transcystic CBD
Transcystic ApproachTranscystic Approach

38. STUDYSTUDY NN SUCCESS (%)SUCCESS (%)
FERZLI, 1991FERZLI, 1991 1313 100100
SAGES, 1994SAGES, 1994 187187 9595
PHILLIPS, 1994PHILLIPS, 1994 111111 9191
DePAULA, 1994DePAULA, 1994 102102 8484
BERTHOU, 1994BERTHOU, 1994 7878 6767
McGRATH, 1994McGRATH, 1994 4444 9393
DION, 1994DION, 1994 1818 9494
STOKER, 1995STOKER, 1995 3333 9494
Transcystic ApproachTranscystic Approach

39. Fogarty
T-tube/no T-tube
/endobiliary stent
Basket
Lithotripsy
(laser or electro-
hydraulic)
Choledochoscopy
Irrigation
+ glucagon
Transductal
Laparoscopic CholedochotomyLaparoscopic Choledochotomy

40. Study Total
patients
Success (%)
Berthou 94 75 96
Franklin 94 60 96
Dion 94 41 93
SAGES 94 39 81
Stoker 95 27 94
DePaula 94 12 100
Ferzli 91 11 100
Phillips 95 3 100
McGrath 94 1 100
Laparoscopic CholedochotomyLaparoscopic Choledochotomy

41. Study PatientsRetained
stone
Morb.Mort.Lenth of
stay
SAGES 226 2.6 5.7 0.4 ?
Berthou 153 1.3 9.4 0 ?
Phillips114 3.6 17.10.9 3.7
DePaula 114 0.9 6.2 0.9 1.7
Petelin 77 1.5 10.40.8 1.9
Franklin 60 0 3.3 1.6 2.1
Stoker 60 5 10 0 2.7
Dion 59 5 25 0 12
McGrath 45 2.2 26.7 0 ?
Ferzli 24 8.3 29.1 0 2.7
F erzl i
Complications of Lap. CBD ExplorationComplications of Lap. CBD Exploration

42. TechniquesTechniques
Irrigation:
•Transcystic flushing
•IV glucagon
•Fluoroscopic monitoring
Balloon:
•4 Fr Fogarty balloon combined with choledochoscope
Basket:
Avoid capture of papilla of Vater
Choledocoscopy / completion cholangiogram
•Primary closure of CDB vs T-tube placement

43. Combined Laparoscopy and ERCPCombined Laparoscopy and ERCP
• 45 pts underwent lap chole w/ intra-op cholangiogram
• 33 pts had succesful intra-op ERCP with extraction of CBD
stones
• No post-op complications related to procedure (i.e.
pancreatitis
bleeding, perforation)
• Mean hospital stay: 2.55+0.89 days
• No pts w/ signs or symptoms of retained CBD stones during
mean post-op follow-up of 9+4.07 months
Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of
gallbladder and bile duct stones: a combined endoscopic-laparoscopic
technique. Int J Surg 2009;7(4):338-46

44. Current TrendsCurrent Trends
National Hospital Discharge Survey database 1979 to 2001:
•Frequency of ERCP vs CBDE
•Beginning of study: 47,000 CBDE’s per year
•End of study: 7,000 CBDE vs 43,000 ERCP
•Complication rates from CBDE
 3.4% at beginning of study
 17.4 at end of study
“ERCP has replaced the need for most but not all CBDE”
“Both choledocholithiasis treatment algorithms and clinical training
paradigms need to account for the rarity of CBDE and high
complication rates associated with it, by incorporation of training
modules in surgical residencies and advocating referral to centers
having expertise in biliary tract operations from surgeons with little
CBDE experience”
Livingstion EH, Rege RV. Technical Complications are Rising as Common
Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433

45. Drainage ProceduresDrainage Procedures
Indications:
• Multiple CBD stones
• Recurrent choledocholithiasis
• Unsuccessful sphincterotomy
• Impacted large CBD stones
• Markedly dilated CBD
Choices:
• Choledochoduodenostomy
• Transduodenal sphincteroplasty
• Choledochojejunostomy

46. CostCost
Hospital cost in management of CBD stones
• 53 pts underwent one-stage or two-stage procedure for CBD stone
• One stage: Lap CBD exploration + lap chole
• Two stage: ERCP followed by lap chole
• 38 pts underwent cost analysis due to uneventful post-op course
• Hospital stay:
 One stage: 2 (0-6) days
 Two stage: 8 (3-18) days
•Significantly lower costs after one-stage approach
•Total hospital cost: 2,636 vs 4,608 euro
•Hospitalization cost: 701 vs 2,190 euro
•Pharmaceutics cost: 645 vs 1,476 euro
•Para-medic personnel: 1,035 vs 1,860 euro
•OR cost (comparable): 1,278 vs 1,232 euro
Topal B et al. Hospital cost categories of one-stage versus two-stage
management of common bile duct stones. SurgEndosc 2009 Jun 25. [Epub
ahead of print]

47. Postoperative ManagementPostoperative Management
• Post-op ERCP
• Lithotripsy
Mechanical (crushing technique)
Extra-corporeal shock wave (electromagnetic)
Intra-corporeal (laser)
• Percutaneous radiologic
• Dissolution (chemical infusion)
Mono-octanoin
Methyl tert-buthyl ether (MBTE)
• Ursodeoxycolic acid
Prevention

48. Treatment of difficult bile duct stones: a Treatment of difficult bile duct stones: a
particularly safe option for octogenariansparticularly safe option for octogenarians
Ten years (1995-2006) : 44 patients median age 80.
Success in 34 (77%). The others required multiple
attempts. All but one achieved complete clearance.
Peroral endoscopic electrohydrolic lithotripsy(EHL) or
laser lithotripsy (ILL), under direct cholangioscopic
visualisation, is an effective treatment for difficult CBD
stones. The technique can be used safely even in frail
and elderly patients. The vast majority of patients may
be expected to remain symptom-free for a prolonged
period.
Swahn F et al Ten Years of Swedish experience with intraductal electrohydrolic
lithotripsy (EHL) and laser lithotripsy (ILL) for the treatment of difficult bile duct
stones: an effective and safe option for octogenarians Surg Endosc. 2009 Oct
23

49. Extracorporeal shock wave lithotripsy: analysis Extracorporeal shock wave lithotripsy: analysis
of factors that favor stone fragmentationof factors that favor stone fragmentation
A high success rate, negligible complications and
non-invasive nature of the procedure make ESWL a
useful tool for removing large CBD stones
Tandan M et al Extracorporeal shock wave lithotripsy of large difficult common
bile duct stones: efficacy and analysis of factors that favor stone fragmentation
J Gastroenterology Hepatol. 2009 Aug India.
283 patients with large CBDS were subjected to ESWL . CBDS were
Fragmented to 5mm or less then extracted via ERCP.
Complete clearance achieved in 239 patients(84.4%),partial in 35 (12.3%)

50. Risk factors for recurrent bile duct stones Risk factors for recurrent bile duct stones
after endoscopic clearance of CBD stonesafter endoscopic clearance of CBD stones
114 patients (2004-2007) S/P ERCP.
The recurrence of CBD stones was more commonly
found in the patients group with type 1 periampullary
diverticulum and multiple sessions of ERCP.
Therefore, patients with these risk factors should be
on regular follow up.
Baek YH et al Risk factors for recurrent bile duct stones after endoscopic
clearance of common bile duct stones Korean J Gastroenterol. 2009 Jul
Korea.

51. ConclusionConclusion
•Multidisciplinary approach to CBD stones
•Pre-operative identification based on risk factors
•Laparoscopic CBD exploration is safe, cost-effective and
carries low morbidity and mortality rate
•Surgeon experience determines:
Lap vs Open approach
Type of drainage procedure if necessary
LAP. CHOLE + CBD STONELAP. CHOLE + CBD STONE
ERCP skillsERCP skillsAvailability of Availability of
equipmentequipment
Technical skillsTechnical skills

53. What to do?What to do?
ERCP
MRCP
Lap CBDLUS
Lap Cholangiogram
Transcystic CBD
Lap
Chole

54. PREOPPREOP INTRAOPINTRAOP POSTOPPOSTOP
SonoSono
EUS EUS
MRCPMRCP
ERCPERCP
Lap transcysticLap transcystic
Lap CBDLap CBD
Open CBDOpen CBD
ERCPERCP
ConclusionConclusion

55. Transcystic ExplorationTranscystic Exploration
Laparoscopic vs Open
•Stones larger than duct ® Dilatation
•Irrigation
•Fluoroscopic wire basket
Stones smaller than 2 to 4 mm
Clockwise rotation while retracting basket
Care not to pull stones into hepatic ducts
•Endoscopic approach
Choledochoscopebasketing
•Long, spiraling, medially inserting cystic duct
Choledochotomy

56. •08% Normal exam
•33% CBD stones

•25% Biliary injury
•100% Success for stone removal
•86% Success for biliary injuries
•05% Complication
Kozarek, Surg Endosc 1995 Nov;9(11):1235-40
ERCPERCP

57. Postoperative ERCPPostoperative ERCP

58. WHAT TO DO? WHAT TO DO?
ERCP
lap CBD
EUS
IOC
MRCP
Lap US

59. CholedochotomyCholedochotomy
•Laparoscopic vs Open
•Large stones: > 1cm
•Anterior wall dissection 1-2 cm distance
•Stay sutures bilaterally
•Vascular supply @ 3 and 9 o’clock
•Longitudinal incision anterior aspect
•Choledochoscope inserted
•Irrigation, basket retrieval, lithotripsy
•12 or 14 Fr T-tube positioned
•CBD closure over T-tube
•Primary closure of CBD
•Completion cholangiogram