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1、Common Bile Duct Stones- Management Options,解放军324医院肝胆外科 张丰深,Gallstones,Incidence 12% men and 24% women (from autopsy study in UK) 10-30% of gallstones will become symptomatic (1-2% per year) Incidence of CBD stones found before or during cholecystectomy 12%,Composition,Cholesterol (70-80%) Uncommon
2、ly pure cholesterol stones (10%) Most have calcium salts in their centre (90%) and 10% of these have enough calcium to be radioopaque Pigment (20-30%) BLACK-secondary stones associated with haemolysis or cirrhosis BROWN-primary stones associated with bile stasis or infection,Shojaiefard A, et al. Va
3、rious techniques for the surgical treatment of common bile duct stones: a Meta review. Gastroenterology Research and Practice, 2009; 1-12,Classification,Primary Stones (5%) Form de novo in CBD Related to biliary stasis and infection Tend to be brown pigment stones Secondary Stones (95%) Formed in ga
4、llbladder Tend to be cholesterol stones,Classification,Retained 2yrs post cholecystectomy,Presentation,Incidental findings at cholecystectomy Biliary colic Jaundice Pancreatitis Cholangitis,The 4 main liver enzymes 毛远丽, 刘志国, 孙志强, 等. 检验与临床诊断-肝病分册. 北京: 人民军医出版社, 2006:131-210,Risk stratification,Risk st
5、ratification,Initial classification of suspected choledocholithiasis according to Cotton criteria as determined by ERCP and MRCP (Calvo et al, Mayo Clin Proc, 2002),Risk Stratification,Predictive scores for each multivariate factor used to produce the scoring system (Menezes et al, BJS, 2002),Risk s
6、tratification,High risk if-CBD 6mm -2 or more abnormal LFTs -cholecystitis/pancreatitis ? Preoperative ERCP Intermediate risk-MRCP Low risk-USS then LC,Imaging,Plain x-ray Ultrasound CT MRCP ERCP,Ultrasound,Most widely used Easy to perform Causes little discomfort Avoid irradiation and contrast medi
7、a High reliability of diagnosing gallbladder stones (95%) Variable reliability of detecting CBD stones 23%-80% depends on body habitus and experience of sonographer,Endoscopic ultrasound,Studies using EUS to evaluate prior to ERCP Avoids cannulation of papilla and avoids the risk of cholangitis and
8、pancreatitis Sensitivity 93% Specificity 97% Approaches ERCP with experience,CT,Sensitivity for CBD stones causing obstructive jaundice 75% Stones usually isodense with bile (not useful for assessment of cholelithiasis) CT cholangiogram unsuitable in jaundice as contrast not excreted Important for i
9、maging of pancreas if suspicion of malignant disease and other abdominal organs,MRCP,Detail now approaches ERCP Technique relies on the principle of imaging fluid columns that are static, better images with dilated ducts and flow artifact can give false positive results Sensitivity 95% Specificity 8
10、9% Accuracy 92%,MRCP,Advantages No irradiation Avoids complications of ERCP in 5%-10% of patients Disadvantages Claustrophobic & noisy Contraindicated if metal implants/foreign bodies Diagnostic only-not therapeutic,ERCP,Considered gold standard for preoperative imaging CBD Both diagnostic and thera
11、peutic,ERCP、取石,Natural history (Tranter, Ann R Coll Surg Engl, 2003),Difficult to predict Prospective study, 1000 cases of symptomatic gallstones, 73% had features suggestive of CBD stones, but had no CBD stones at OT and considered to have passed the stone spontaneously Cases with cholangitis or ja
12、undice were less likely to pass spontaneously,Primary (common) bile duct stones,Usually due to ampullary stenosis, diverticula or impaired bile duct motility Often require choledochojejunostomy (subject to circumstances and patient age) Management with choledochotomy & T-tube drainage alone associat
13、ed with recurrence rates up to 41% Laparoscopic choledochoduodenostomy-an option for advanced laparoscopic surgeon, but concerns regarding long term consequences of bilioenteric reflux,Secondary bile duct stones,Found at the time of or within 2 years of cholecystectomy 12% cholecystectomies 90% have
14、 preoperative indications (jaundice, pancreatitis or abnormal LFTs) 5%-10% have no pre-op indication and are detected at IOC (filling defect, absence of filling terminal segment of CBD or delay/absence of flow into duodenum),The best management of CBD stones is still a matter of debate,ERCP,General
15、agreement ERCP is preferable in Post-cholecystectomy patients High risk surgical patients who still have a gallbladder Severe acute cholangitis Selected patients with acute biliary pancreatitis Failed transcystic exploration with a CBD 8mm,ERCP,Areas of disagreement First line management of CBD ston
16、es Preoperative CBD clearance,ERCP,CBD clearance 90%-95% with successful sphincterotomy (papillary dilatation is an alternative) Overall clearance 80%-95% (improves with experience of endoscopist) Major complications in 10%,ERCP complications,Acute (5%) Haemorrhage 1%-6% Acute pancreatitis 1%-19% Ch
17、olangitis Retroduodenal perforation 1%-2% Failure to clear or access duct 2%-18% Overall procedure mortality 1% 30 day mortality can reach 15% (reflects severity of underlying disease),ERCP complications,Medium Recurrent stones 2%-14% Cholangitis 1%-6% Bacterobilia 60% Late Bile duct malignancy 2% (
18、Prat et al, Gastroenterology, 1996 & Tanaka et al, Gastrointest Endosc, 1998),Difficult bile duct stones at ERCP,Stones 15mm Intrahepatic stones Multiple stones Impacted stones Stone proximal to biliary stricture Tortuous bile duct Disproportionate size of bile duct stone Duodenal diverticulum Bilro
19、th 2 reconstruction Surgical duodenotomy,Adjuvant techniques,Mechanical lithotripsy Extracorporeal shockwave lithotripsy Chemical dissolution Successful stone fragmentation has been reported in up to 80% of patients, but major drawback is the need for multiple treatment sessions and repeat ERCP to r
20、etrieve stone fragments,ERCP stent insertion,5% of cases where stone extraction fails either a nasobiliary tube or stent should be inserted for CBD decompression Stents may block after a few months, but bile often drains around stent If surgically unfit can change stents if jaundice recurs Recurrent
21、 episodes of cholangitis can lead to secondary biliary cirrhosis in the long term so careful consideration before surgery is totally discounted,Preoperative ERCP,Eliminates the intraoperative dilemma as to how to manage CBD stones Exposes a number of patients to an unnecessary procedure and associat
22、ed complications Successful cannulation of papilla 96.8% with stones cleared in 86%, 13% unnecessary ERCP with failure rate 4.5% and morbidity 2.2% (Hamy, Surg , Endosc, 2003) Randomised study has shown no significant advantage for patient treated with preoperative ERCP with sphincterotomy vs open c
23、holecystectomy and CBD exploration (Neoptolemos et al, Br J Surg, 1987),Preoperative ERCP,Cholecystectomy should routinely follow clearance of CBD except in those too frail for a general anaesthetic If the gallbladder is left intact it can be expected that 47% of patients will develop at least on re
24、current biliary event (Boerma et al, Lancet, 2002),Intraoperative ERCP,Described in literature but few centers consider it an appropriate use of resources,Postoperative ERCP,Dictated by local expertise and practice Small (5mm) stones found at IOC could be left to pass, follow up to 33 months found 2
25、9% developed symptoms and were subsequently managed successfully with ERCP (Ammori et al, Surg Endosc , 2000),Laparoscopic transcystic CBD exploration,Fibreoptic instruments or radiologically guided wire baskets or balloons Two randomised trials have shown 60%-70% of patients are able to have their
26、calculi cleared via the cystic duct (Cuscherieri et al, Surg Endoscopy 1999 & Rhodes et al, Lancet 1998) 1-2% patients managed without cholangiogram will present with a retained stone,Transcystic exploration,Standard dissection to identify cystic duct Cystic duct opened distal to a previously applie
27、d clip Milk stones from cystic duct Cholangiogram Assessment of stone and duct size Tiny stones or possible sphincter of oddi spasm try glucagon and flush with saline then repeat cholangiogram,Transcystic exploration,Nathanson basket fed into CBD (ensure tip of basket well back from tip to avoid duc
28、t perforation) Under image intensification tip positioned, basket opened and stone removed If stone impacted can dislodge with 4Fr fogarty catheter or perform choledochoscopy,Techniques to improve transcystic clearance,Careful dissection of cystic duct/CBD junction Avoidance of spiral valves when en
29、tering cystic duct Careful examination of cholangiogram Approach cystic duct from different or extra ports Dilation of cystic duct with a balloon Choledochoscopy via cystic duct Vary retraction on fundus Cystic duct closure clips or endoloops Subhepatic drainage,Trans cystic exploration success,Ston
30、es few in number Small in size (1cm) Situated in the common duct or distal to the cystic duct entry,Choledochotomy preferable if,Large and/or numerous stones Common hepatic duct or intrahepatic ducts Careful consideration of laparoscopic strategies to be employed, equipment required and adequacy of
31、assistance,Indications for choledochotomy,Unsuccessful transcystic exploration Cystic duct diameter smaller than stones CBD 8mm Multiple large stones Impacted stones with features of cholangitis Ampullary diverticulum on IOC Previous bilroth 2 gastrectomy Previous failed ERCP Contraindication to pos
32、t post-op ERCP ERCP unavailable,Laparoscopic choledochotomy,35% of patients transcystic approach fails to clear the CBD Only absolute contraindication in a CBD 8mm Consider that 1/3 stones detected at IOC will pass spontaneously and exploration of a small duct may result in increased morbidity Surge
33、on must be appropriately trained,Laparoscopic choledochotomy,Deflate duodenum with NGT Extraport to retract duodenum Leave cholangiocatheter in place to prevent deflation of CBD Laparoscopic knife for choledochotomy Flushing, Fogarty catheter and basket to remove stones Once duct confirmed cleared (
34、choledochoscopy) consider: T tube; primary closure +/- antegrade stent across ampulla; cystic duct tube decompresion,CBD decompression,Controversy over T-tube, antegrade stents, cystic duct stents or no drainage If any doubts about free postoperative drainage of bile through ampulla, then decompress
35、 Most likely to need decompression if stone was impacted, extensive ampullary monipulation or cholangitis Subhepatic drainage essential,Reasons to consider conversion to open choledochotomy,Unsuccessful transcystic CBD exploration Unsuccessful laparoscopic CBD exploration Multiple CBD stones (10) La
36、rge CBD stones Intrahepatic or proximal duct stones Impacted stones Failed or unavailable ERCP,Open choledochotomy,Successful exploration involves an adequately sized choledochotomy to facilitate removal of stones and choledochoscopy Introduction of choledochoscopy (1970-80s) led to a decline in ret
37、ained stones from 10% to 1.2% Choledochoscopy allows visualisation of several generations of upper ducts (when dilated) and the ampulla,T-tube,CBD decompression Allows access to biliary tree for postoperative cholangiography and reexploration without the need for reoperation,T-tube complications,Flu
38、id and electrolyte disturbances Bile leak around T-tube Bile leak after removal 1%-19% Silicon coated latex tubes cause less fibrotic response than red rubber tubes, need to stay in longer (4-6weeks) to avoid biliary peritonitis on removal Advocated for complicated cases such as cholangitis, pancrea
39、titis or difficult exploration In the absence of these factors primary closure has been shown to be as safe as T-tube drainage in several randomised trials (De Roover et al, Acta Chir Belg, 1989; Sheen-Chen and Chou, Acta Chir Scand, 1990 & Williams et al, ANZ J Surg 1994),No single technique will b
40、e applicable to the management of all CBD stones,Management of CBD stones,Preoperative ERCP and laparoscopic CBD clearance have equivalent overall outcomes (Rhodes et al, Lancet, 1998) ERCP LCBDE CBD clearance 75%-96% 90% Morbidity 13% 8% Mortality 1% 1% Pancreatitis 3% 1% (Tranter and Thompson, BJS
41、, 2002) Patients who have a transcystic approach have a shorter hospital stay,Options if laparoscopic transcystic exploration fails,Ligate cystic duct, complete cholecystectomy and rely on postoperative ERCP Perform laparoscopic choledochotomy Laparotomy and open CBD exploration,Options if laparosco
42、pic choledochotomy fails,Insert T-tube and extraction of stones after 6 weeks Postoperative ERCP Conversion to open CBD exploration,Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2005),Trial Randomization,Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2005),Randomized trial in Br
43、isbane (Nathanson et al, Ann Surg, 2005),Recurrent or retained CBD stones,Recurrent in 10% cases More common in patients with primary duct stones, CBD 16mm and periampullary diverticula Retained stones found on T-tube cholangiogram best dealt with by ERCP Takes 6 weeks for tract to mature and allow
44、percutaneous radiologically guided stone extraction or choledochoscopy successful in 95% and carries less risk of pancreatitis or haemorrhage,Cholelithiasis,Suspicion of CBD stones,Selective per-op cholangiogram,No stones,LC,Routine per-op cholangiogram,Routine per-op ERCP,CBD stones,CBD stones,EST
45、and duct clearance,LC,LCBDE,OCBDE,Post-op ERCP,Failure,Failure,Success,Failure,OCBDE,LCBDE,Failure,Algorithm showing the available strategies for management of common bile duct stones,Shojaiefard A, et al. Various techniques for the surgical treatment of common bile duct stones: a Meta review. Gastr
46、oenterology Research and Practice, 2009; 1-12 -以ERCP为先导,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1):
47、33-40,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Group 2 patients,Group 1 patients,Group 3 patients,Group 4 patients,Therapeutic ERCP,MRCP,LC+IOC,LC,(),(),Liu TH, et al. Patient evaluation and management with selective
48、 use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 23
49、4(1): 33-40,胆囊结石继发胆总管结石危险度分级 解放军第324医院肝胆外科,Gallbladder stones,Low suspicion of CBD stones,Intermediate Suspicion of CBD stones,high suspicion of CBD stones,LC,Lap-IOC,No CBD stones,CBD stones,MRCP,No CBDS,CBDS,Therapeutic ERCP,经胆囊管LCBDE,经胆总管切开LCBDE,Failure,解放军第324医院肝胆外科胆结石微创诊疗流程,Failure,Success,No suspicion of CBD stones,Management of CBDS depends on 总的趋势是无/微创、cost-effective 病人一般情况能否耐受麻醉和