Management of Common Bile Duct stones Dr Daniel

Management of Common Bile Duct stones Dr. Daniel TM Chung Department of Surgery, Pamela Youde Nethersole Eastern Hospital, HK East Cluster Joint Hospital Surgical Grand Round Sept. , 2008

Background 10%-18% of patients undergoing cholecystectomy have CBD stones Before the advent of ERCP/laparoscopy, patients with choledocholithiasis required open surgical treatment Development of endoscopy and laparoscopy, choices become more

Nowadays… The optimal treatment of choledocholithiasis is still a controversial issue Stone size Number of stone Timing of discover of CBD stone Size of cystic duct / CBD Patient’s general condition Previous surgery Availability of expertise Facilities

Objective To discuss various techniques for CBD clearance

USG Suspicion of CBD stones (patient’s condition) ERCP MRCP Preoperative ERCP +/- ES Lap. Cholecystectomy +/ - IOC +/- open Intra-op ERCP +/- ES ECBD (laparoscopic / open approach) Post-op ERCP +/- ES Stone Clearance

Preoperative Endoscopic Therapy Elderly / Debilitated patients Jaundiced / cholangitis / severe pancreatitis 75 -84% of patient remains symptom free up to 70 -month follow -up Schreurs WH et al. Dis Surg 2004 Vazquez-Inglesias JL et al. Surg Endosc 2004

Disadvantages Less patient compliance Two-session treatment Longer hospital stay Risk of ERCP Routine pre-op ERCP: Up to 61% of patients with suspected common duct stones undergo an unnecessary ERCP with its associated morbidity Nataly Y et al. ANZ J Surg 2002

Postoperative endoscopic therapy Definitive treatment of CBD stones when: Lap ECBD failed to clear the duct Retained stones are discovered postoperatively Incidence 2. 5% Comorbidities make a prolonged operation risky CBD small and prone to post-op stricture Disadvantage: possibility of failure in cannulation of CBD / removal of CBD stones

ECBD (Open/Laparoscopic approach) Endoscopically difficult stones: Stones > 15 mm Multiple stones Impacted stones Distorted anatomy Tortuous bile duct Duodenal diverticulum Billroth II reconstruction / surgical duodenotomy

Laparoscopic ECBD Potential benefit: minimally invasive, shorter hospital stay, less pain, better cosmetic result Significantly reduced hospital stay compared with pre-op ERCP/ES + LC Cuschieri A et al. Surg Endoc 1999 100% success rate in salvaging failed pre-op ERCP Tai CK, Tang CN et al. Surg Endosc 2004 Transcystic technique vs. choledochotomy

Transcystic technique Successful ductal clearance in 80– 90% of patients Cuschieri A et al. Surg Endosc 1999 Thompson MH et al. Br J Surg 2002 Rojas-Ortega S et al. J Gastrointest Surg 2003 Complication rate: 5 -10% Mortality rate: 0 -2% Duration of hospitalization: 1 -2 days Main advantage: avoid choledochotomy

Transcystic technique Choledochotomy (+/- choledochoscopy) Few in number of stones Numerous stones < 1 cm in size Large stones Situated distal to cystic duct entry Stones in CHD

Laparoscopic Exploration of the Common Bile Duct: 10 -year Experience of 174 Patients from a Single Centre 1995 -2005 1144 ES / 22 open ECBD / 174 lap ECBD M: F = 71: 103 Mean age: 63 (SD = 16) 156 choledochotomies / 18 transcystic duct exploration Tang and Li, HKMJ 2006; 12: 191 -6

Indications of LECBD Patients no. n=174 68 (39%) Young patient (<60 years) with concomitant gallstones and CBD stones Previous failed ERCP 59 (34%) Large (>2 cm) or multiple CBD stones RPC (for drainage choledochoenterostomy) 40 (23%) 34 (20%)

Morbidity / Mortality Patients No. Overall Morbidity 34 (19. 5%) Bile leak / stent migration / collection 15 (8. 6%) Residual stones 14 (8. 0%) Wound infection / bleeding 4 (2. 3%) Bile duct injury 4 (2. 3%) Blocked stent 2 (1. 1%) Cholangitis 2 (1. 1%) Retained stone inside peritoneal cavity 1 (0. 6%) Duodenal injury 1 (0. 6%) Intra-abdominal collection 1 (0. 6%) Intestinal obstruction 1 (0. 6%) Mortality (secondary to bile leak and collection) 1 (0. 6%)

Edward H. Philips et al. J Gastrointest Surg, 2008 Cuschieri Sgourakis Pre-op ES LC+LCBD E n=150 N=150 Morbidity 12. 8% 15. 8% Mortality 1. 5% CBD clearance (% of operations) Length of hospital stay (mean days) P value Pre-op ES LC+LCBD E P value N=36 N=42 0. 54 13% 17% <0. 87 0. 75% NS 2% 2% NS 84% 0. 96 86% 84% NS 9 6 <0. 05 7. 4 9 0. 07

Nethanson Rhodes LCBDE (choledochotomy) Post-op ES n=43 Primary ductal clearance 100% 74% Final ductal clearance 100% Morbidity P value LCBDE (transcystic) Post-op ES P value n=40 0. 20 75% NA 100% NS 100% 93% NA 17% (14. 6% bile leak) 13% NS 0 0 NA Mortality 0 0 NS 0 0 NA Length of hospital stay (mean days) 6. 4 7. 7 0. 57 1 3. 5 NA

Intra-operative ERCP: Advantages Treatment in one session Avoids overestimation of patients selected for pre-op ERCP on the basis of imaging as well as biochemical and clinical criteria Possible to carry out main bile duct laparoscopic or open exploration during same procedure in case of failure Catheterization and positioning of papillotom facilitated by a rendezvous between guidewire inserted through cystic duct into duodenum and the papillotom itself

Rendezvous

Intra-operative ERCP: Disadvantage Increase in laparoscopic cholecystectomy surgery duration Logistic difficulties in the procedure organization May require multiple units (e. g. surgeons and endoscopists) Experts required Supine position for ERCP

Preoperative Endoscopic Sphincterotomy versus Laparoendoscopic Rendezvous in Patients with Gallbladder and Bile Duct Stones Prospective, randomized trial 91 elective patients with cholelithiasis and CBD stones Diagnosed at MRC Mario Morino et al. Annals of Surgery, 2006

Group II Pre-op ERCP +ES followed by LC LC +intraop ERCP +ES No. of patients (n) 45 46 CBD clearance 80% 95. 6% P=0. 06 Morbidity rate 8. 8% 6. 5% NS Mortality rate 0% 0% Hospital Stay (day) 8. 0 4. 3 P < 0. 0001 Mean total cost (Euro) 3834 2829 P < 0. 05

Two-stage Treatment with Preoperative ERCP compared with Single-stage Treatment with Intraoperative ERCP for Patients with Symptomatic Cholelithiasis with Possible Choledocholithiasis Prospective randomized study Success rate: similar Frequency of residual CBD stones, conversion rate, surgical morbidity: no differences Intra-op ERCP group: less morbidity, a shorter hospital stay, reduced costs Rabago LR et al. Endoscopy, 2006

Our Hospital’s experience: LC + intra-op ERCP June 2006 - September 2008 n=12 (M: F = 9: 3) Mean Age = 61. 4 (22 79) Indications: Cholangitis: 11 Biliary pancratitis: 1

Cannulation rate: 100% Stone clearance: 66% (8 cases) 2 need conversion to laparotomy + ECBD 2 need post-op ERCP Morbidity No major surgical complications 1 case of severe pneumonia Mortality: 0% Post-op hospital stay: mean 5. 75 days (1 – 14 days)

Operation Timing Mean operation time: 134. 18 minutes (61 – 215 minutes) Mean operation time (June 2006 – Feb 2008) 150. 83 minutes (120 – 215 minutes) Mean operation time (Feb – Sept 2008) 114. 2 minutes (61 – 210 minutes)

Intraoperative ERCP Reasons for improvement in surgical time: Improvement in facilities Better cooperations among surgeons / endoscopists, nurses and other theatre staffs Mastering of techniques

Surgical versus Endoscopic Treatment of Bile Duct Stones 3974 articles reviewed 13 trials randomised 1251 patients 8 trials (n=760) (ERCP vs open surgical clearance) 3 trials (n=425) (pre-op ERCP vs lap clearance) 2 trials (n=166) (post-op ERCP vs lap clearance) Martin DJ et al. Cochrane Database Syst Rev. 2006

A significantly increased number of total procedures per patient was seen in ERCP arms ERCP was less successful than open surgery in stone clearance; with a tendency towards higher mortality Lap CBD stone clearance was as effective as pre- or post-operative ERCP; no significant difference in morbidity and mortality Laparoscopic trials: shorter hospital stays in surgical arms Insufficient data reported for cost analysis Conclusions: … In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones…

Conclusion Controversial Depends on expertise available, instruments, personal experience, patient condition