1 / 36

The management of patients with CBD stone and gallstone

The management of patients with CBD stone and gallstone. D. Chung. Introduction. CBD stone present in 4-10% of those presenting with indication for lap cholecystectomy In era of open cholecystectomy, there was routine use of IOC +/- exploration (1 stage)

Thomas
Télécharger la présentation

The management of patients with CBD stone and gallstone

An Image/Link below is provided (as is) to download presentation Download Policy: Content on the Website is provided to you AS IS for your information and personal use and may not be sold / licensed / shared on other websites without getting consent from its author. Content is provided to you AS IS for your information and personal use only. Download presentation by click this link. While downloading, if for some reason you are not able to download a presentation, the publisher may have deleted the file from their server. During download, if you can't get a presentation, the file might be deleted by the publisher.

E N D

Presentation Transcript

  1. The management of patients with CBD stone and gallstone D. Chung

  2. Introduction • CBD stone present in 4-10% of those presenting with indication for lap cholecystectomy • In era of open cholecystectomy, there was routine use of IOC +/- exploration (1 stage) • With introduction of lap chole, there was move away from IOC and surgical management of CBD to 2 stage procedure with preop or postop ERCP

  3. Introduction • Reason: Lack of expertise for LECBD and reluctance to convert to open • But, pre-op ERCP carries a significant false-positive rate • Today, the advance of lap ECBD is increasingly reported to return the management of CBD stones to a one stage surgical procedure

  4. Introduction • Patient presented with CBD stone and gallstone • Pre op ERCP + LC (2 stage approach) • LC + IOC +/- LECBD (1 stage approach)

  5. Introduction • Two-staged approach • ERCP & Laparoscopic cholecystectomy • Heinennan PM et al, Ann Surg 1989 • Wilson P et al, Lancet 1991 • Surick B et al, Surg Endosc 1993 • Mayer C et al, J Hepato Pancreat Surg 2002 • Chan CM et al, ANZ J Surg 2005

  6. Introduction • One-staged approach • Laparoscopic cholecystectomy + laparoscopic exploration of common bile duct Rhodes M et al, Lancet 1998 Cuschieri A et al, Semin Laparosc Surg 2000 Lezoche E et al, Semin Laparosc Surg 2000 Nathanson LK et al, Ann Surg 2005 Paganini AM et al, Surg Endosc 2007

  7. 2 stage procedure (ERCP + lap cholecystectomy)

  8. 2 stage procedure • Methods • Pre-op ERCP + lap chole • Lap chole + post op ERCP

  9. 2 stage procedure • Advantage • Avoid the need of T-tube • Avoid the need of choledochotomy • Avoid the complications of ECBD • Need not to have expertise/operation set-up on LECBD

  10. 1 stage procedure (Lap cholecystectomy + IOC +/- LECBD)

  11. 1 stage procedure • Two methods for LECBD • 1) Transcystic duct exploration • Preferred method for small CBD stones and small calibre CBD • 2) Choledochotomy • Multiple (>3), Large CBD stone (>1 cm ) • Failed transcystic duct treatment • CBD > or = 9 mm on cholangiogram

  12. 1 stage procedure • Methods for closure of choledochotomy • T-T closure • Primary closure with stent • Primary closure without stent

  13. 1 stage procedure • Factors affecting the result of LECBD • Approach to LECBD (Trans-cystic vs choledochotomy) • Method for closure of choledochotomy • Morbidity • Bile leakage

  14. 1 stage procedure • Advantage • 1 stage procedure/1 admission • Less costly • Shorter hospital stay (with transcystic duct exploration) • Avoid complications of ERCP • Fail ERCP • Preserve biliary sphincter • Avoidance of risk of further stone migration from gallbladder to CBD while awaiting for lap chole

  15. Evidence?

  16. Evidence (Case series) • Case series for LECBD(Most are transcystic duct exploration) • 300 patients, 90% ductal clearance • Martin IJ et al, Ann Surg 1998 • 129 consecutive patients, 92% ductal clearance • Rhodes M et al, Br J Surg 1995 • 268 consecutive patients, 94.3% ductal clearance • Pahanini AM et al, Ann Ital Chir 2000

  17. Evidence (Randomised trial) • Two stage approach VS LECBD (transcystic exploration or choledochotomy) 1) Rhodes M et al, Lancet 1998 (40 cases/arm) (LC + post op ERCP VS LECBD ) 2) Cuschieri A et al, Surg Endos 1999 (150 cases/arm) (Pre op ERCP + LC VS LECBD, multicenter trial ) • Conclusion: Same ductal clearance rate, shorter hospital stay in LECBD group

  18. Evidence (Randomised trial) • Post op ERCP VS LECBD (Choledochotomy) Nathanson LK et al, Ann Surg 2005 • 372 cases of CBD stones, with 86 cases (23%) of failed transcystic duct exploration recruited to trial • Choledochotomy 41 VS ERCP clearance 45 • No difference in operative time, retained stone rate, overall morbidity and mortality

  19. Evidence (Randomised trial) • Management of CBD stones, laparoscopic versus endoscopic approach, a comparative study (pre-op ERCP + LC Vs LC + IOC +/- LECBD) • Elbatanouny, A, Zeineldin, A • British Journal of Surgery, Volume 93, September 2006 • No significant difference in the clearance rate between 2 management options • High rate of unnecessary ERCP in pre-op ERCP group (51.5%)

  20. Evidence (meta-analysis) • Meta-analysis of endoscopy and surgery versus surgery alone for CBD stone with the gallbladder in situ • Clayton, E. S., Connor, S • British Journal of Surgery Volume 93(10), October 2006

  21. Evidence (meta-analysis) • They identified 12 studies on Medline and ISI databases that met the inclusion criteria for data extraction (using keywords) • Inclusion and exclusion criteria • RCT in English language up to the end of March 2006 • Review articles, retrospective analysis and abstracts were not included

  22. Table 1

  23. Evidence (results) • Outcomes of 1357 patients were studied • Successful duct clearance • 77.6% in endoscopy + surgery group • 79.8% lap CBD surgery group • p=0.870 (n.s) • Mortality • 0.9% endoscopy + surgery group • 0.5% lap CBD surgery group • p=0.720 (n.s)

  24. Evidence (results) • Total morbidity rate • 13.6% in endoscopy + surgery group • 17.1% in lap CBD surgery group • p=0.710 (n.s) • Need of additional procedures after initial intervention • 10.2% in endoscopy + surgery group • 9.5% in lap CBD surgery group • p=0.90 (n.s)

  25. Evidence (results) • No significant difference of successful duct clearance, mortality, total morbidity, major morbidity, need for additional procedures between the endoscopic and surgical groups

  26. Primary closure Vs T-tube • RCT on Primary Closure vs T-Tube Closure after choledochotomy • Ha & Li et al, IHBPA 2004

  27. Evidence (Primary closure Vs T-tube) • Primary closure of the CBD is feasible and as safe as T tube insertion after laparoscopic choledochotomy for stone disease • Similar morbidity, no mortality • 1 bile leak(6.6%) in primary closure group and no bile leak in t-tube group • Similar operative time ( 108.4 Vs 116.8 minutes, p=0.52) • Shorter postoperative hospital stay (4 Vs 8 days, p<0.001)

  28. Evidence • No consensus to whether which approach is better • Similar ductal clearance rate • Similar morbidity and mortality

  29. UCH experience for LECBD

  30. UCH experience 2005-2006 • Case number for LECBD • 25 • Age • Mean 70.3 (47-87) • Operation time • Mean 212 mins (145-295) • Stone clearance rate • 96% (1 case with residual CBD stones)

  31. UCH experience 2005-2006 • Average CBD diameter (cm) • Mean 1.4 (1-2.5) • Number of CBD stones • 1-12 • Conversion rate • 0% • All performing choledochotomy • Closure of choledochotomy • 23 with placement of T-tube • 2 with transcystic duct drain

  32. UCH experience 2005-2006 • Hospital stay • Mean= 12.8 days (9-17) • Morbidity • 1 case of retained stone 1/25 (4%) • 1 case with distal CBD stricture 1/25 (4%) • 1 case with retained transcystic duct drain require laparotomy and ERCP 1/25 (4%) • Mortality • 0%

  33. UCH experience 2005-2006 • Follow-up period • 5-20 months

  34. Conclusion • Both 1 stage or 2 stage approaches have similar outcomes, and treatment should be determined by local resources and expertise

  35. Our practice for LECBD • LC + LECBD (1 stage approach) • Good surgical risk • CBD > 1cm • 1 or more stones • Especially case with large and multiple stones • Fail ERCP

  36. End

More Related