CBD stones.ppt - SUNY Downstate Medical CenterTitle Microsoft PowerPoint - CBD stones.ppt [Compatibility Mode] Author aleybeng Created Date 7/29/2008 11:24:21 AM

5 Q estions5 Q estions5 Questions5 Questions1.1. Which of the following is the single best predicting factor for presence of CBD stones?Which of the following is the single best predicting factor for presence of CBD stones?

a.a. Alkaline phosphataseAlkaline phosphataseb.b. ASTASTc.c. Total bilirubinTotal bilirubind.d. AmylaseAmylase

2.2. Which of the following is the best approach for a patient with CBD stones of more than 6mm diameter, cystic duct of 4mm diameWhich of the following is the best approach for a patient with CBD stones of more than 6mm diameter, cystic duct of 4mm diameterter, , and CBD of more than 6mm diameterand CBD of more than 6mm diameter

aa Transcystic exploration with basket stone retrievalTranscystic exploration with basket stone retrievala.a. Transcystic exploration with basket stone retrievalTranscystic exploration with basket stone retrievalb.b. Choledochotomy with irrigation techniqueCholedochotomy with irrigation techniquec.c. Transcystic exploration with irrigation techniqueTranscystic exploration with irrigation techniqued.d. Choledochotomy with balloon sweepCholedochotomy with balloon sweepe.e. Transcystic exploration with lithotripsyTranscystic exploration with lithotripsy

3.3. CBD stones found in a patient one year after cholecystectomy are most likely:CBD stones found in a patient one year after cholecystectomy are most likely:a.a. RetainedRetainedb.b. RecurrentRecurrent

PrimaryPrimaryc.c. PrimaryPrimaryd.d. b and cb and c

4.4. When sphincterotomy or papillotomy are unsuccessful, the surgeon can perform which of the following for proper drainage of CBWhen sphincterotomy or papillotomy are unsuccessful, the surgeon can perform which of the following for proper drainage of CBD D stonesstones

a.a. Choledochotomy and stone retrievalCholedochotomy and stone retrievalb.b. Transduodenal sphincteroplastyTransduodenal sphincteroplastyc.c. CholedochoduodenostomyCholedochoduodenostomyd.d. CholedochojejunostomyCholedochojejunostomy

All of the aboveAll of the abovee.e. All of the aboveAll of the above5.5. When the ampulla is exposed through duodenal access, what is the preferred incision for access to the Common Bile DuctWhen the ampulla is exposed through duodenal access, what is the preferred incision for access to the Common Bile Duct

a.a. 5 o’ clock5 o’ clockb.b. 3 o’clock3 o’clockc.c. 11 o’clock11 o’clockd.d. 2 o’clock2 o’clocke.e. 12 o’clock12 o’clock

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Case presentationCase presentationCase presentation Case presentation

Joel A. Ricci, M.D.Joel A. Ricci, M.D.SUNY Downstate Medical CenterSUNY Downstate Medical Center

Long Island College HospitalLong Island College HospitalLong Island College HospitalLong Island College HospitalDepartment of SurgeryDepartment of Surgery

Morbidity and Mortality ConferenceMorbidity and Mortality Conference


Initial p esentationInitial p esentationInitial presentationInitial presentation

28 y.o. African American female c/o RUQ 28 y.o. African American female c/o RUQ pain for 2 weeks worsened by meal pain for 2 weeks worsened by meal p yp yintake, no other symptomsintake, no other symptomsPMHx: GERDPMHx: GERDPMHx: GERDPMHx: GERDPSHx: nonePSHx: noneNKDANKDANKDANKDANo tobacco or EtOH historyNo tobacco or EtOH history


Ph sical E amPh sical E amPhysical ExamPhysical ExamVitals: T: 98.9, BP: 145/94, HR: 97Vitals: T: 98.9, BP: 145/94, HR: 97Vitals: T: 98.9, BP: 145/94, HR: 97Vitals: T: 98.9, BP: 145/94, HR: 97Abd: mildly obese, RUQ/epigastric tenderness Abd: mildly obese, RUQ/epigastric tenderness without Murphy’s signwithout Murphy’s signwithout Murphy s signwithout Murphy s signAdmission Labs:Admission Labs:CBC: 11.5/11/35/379CBC: 11.5/11/35/379CBC: 11.5/11/35/379CBC: 11.5/11/35/379Chem: 140/4/102/25/12/0.6/100Chem: 140/4/102/25/12/0.6/100Alk Phos: 394Alk Phos: 394Alk Phos: 394Alk Phos: 394ALT: 192ALT: 192T bili: 0 7T bili: 0 7T. bili: 0.7T. bili: 0.7


ImagingImagingImagingImaging

RUQ Sonogram: Cholelithiasis and RUQ Sonogram: Cholelithiasis and choledocholithiasis with CBD dilation to 8mm choledocholithiasis with CBD dilation to 8mm and minimal intrahepatic biliary dilationand minimal intrahepatic biliary dilationp yp yERCP: multiple gallstones within opacified GB ERCP: multiple gallstones within opacified GB with numerous filling defects noted within the with numerous filling defects noted within the CBD and common hepatic duct, CBD dilatedCBD and common hepatic duct, CBD dilatedCBD and common hepatic duct, CBD dilated CBD and common hepatic duct, CBD dilated to 11mmto 11mmSphincterotomy with several attempts @ Sphincterotomy with several attempts @ balloon and basket stone retrievalballoon and basket stone retrievalballoon and basket stone retrieval balloon and basket stone retrieval unsuccessfully.unsuccessfully.10 French 5cm straight biliary stent placed10 French 5cm straight biliary stent placed



Ope ati e p oced e 1Ope ati e p oced e 1Operative procedure 1Operative procedure 1

Ex Lap, cholecystectomy, CBD explorationEx Lap, cholecystectomy, CBD explorationMarkedly scarred and edematous GB with Markedly scarred and edematous GB with cholecystoduodenal fistulacholecystoduodenal fistulacholecystoduodenal fistulacholecystoduodenal fistulaLarge amount of gallstonesLarge amount of gallstonesEdematous cystic duct w/o plane of dissection Edematous cystic duct w/o plane of dissection b/ GB d CBDb/ GB d CBDb/w GB and CBDb/w GB and CBDGB transected at distal portionGB transected at distal portionProximal CBD stones removed (5)Proximal CBD stones removed (5)Proximal CBD stones removed (5)Proximal CBD stones removed (5)Palpable CBD stones down into ampullaPalpable CBD stones down into ampullaPalpated stentPalpated stent



Transduodenal SphincteroplastyTransduodenal SphincteroplastyKocher maneuver: duodenal mobilizationKocher maneuver: duodenal mobilizationLongitudinal incisionLongitudinal incisionLongitudinal incisionLongitudinal incisionAmpulla incised @ 11 o’clockAmpulla incised @ 11 o’clockCBD incised w/ curved dissector and Pott scissors CBD incised w/ curved dissector and Pott scissors //slowlyslowlyEdges sutured to duodenal mucosa w/ 3Edges sutured to duodenal mucosa w/ 3--0 PDS 0 PDS Impacted stones removed (3)Impacted stones removed (3)Impacted stones removed (3)Impacted stones removed (3)Balloon sweep with 6 Fr Fogarty catheter w/ Balloon sweep with 6 Fr Fogarty catheter w/ further stone removal (4)further stone removal (4)



CholedochoscopyCholedochoscopyVisualized entire duct Visualized entire duct No evidence of additional stonesNo evidence of additional stonesNo evidence of additional stonesNo evidence of additional stonesIrrigation with no further materialIrrigation with no further material

ClosureClosureClosureClosureSphincteroplasty sized with progressive Bakes Sphincteroplasty sized with progressive Bakes dilators up to 11mmdilators up to 11mmD oden l lo e one l e 3D oden l lo e one l e 3 0 p olene0 p oleneDuodenal closure: one layer 3Duodenal closure: one layer 3--0 prolene 0 prolene continuous continuous JP placed around duodenotomy and CBD closureJP placed around duodenotomy and CBD closure


Post ope ati e co sePost ope ati e co sePost operative coursePost operative course

Pt tolerated procedure wellPt tolerated procedure wellPOD 1POD 1 –– 4: Afebrile normal labs4: Afebrile normal labsPOD 1 POD 1 4: Afebrile, normal labs4: Afebrile, normal labsPOD 5: JP removed, tolerated clearsPOD 5: JP removed, tolerated clearsPOD 6 t l t d l di t d/ hPOD 6 t l t d l di t d/ hPOD 6: tolerated regular diet, d/c homePOD 6: tolerated regular diet, d/c homePOD 31: outpatient doing wellPOD 31: outpatient doing well


Diagnosis and Management of Diagnosis and Management of Common bile duct stonesCommon bile duct stones

Joel A. Ricci, M.D.Joel A. Ricci, M.D.SUNY Downstate Medical CenterSUNY Downstate Medical Center

Department of SurgeryDepartment of SurgeryDepartment of SurgeryDepartment of SurgeryMorbidity and Mortality ConferenceMorbidity and Mortality Conference

June 20, 2008June 20, 2008


Objecti esObjecti esObjectivesObjectives

PrePre--operative identification of risk factors operative identification of risk factors associated to choledocholithiasisassociated to choledocholithiasisLearn the different approaches in Learn the different approaches in managing CBD stonesmanaging CBD stonesmanaging CBD stonesmanaging CBD stonesIntraIntra--operative decision making according operative decision making according to patient’s circumstancesto patient’s circumstancesto patient s circumstancesto patient s circumstancesRecognizing complications associated with Recognizing complications associated with diff t hdiff t hdifferent approachesdifferent approaches


Histo and etiologHisto and etiologHistory and etiologyHistory and etiology

Ludwig Courvoisier (Sweden) 1890:Ludwig Courvoisier (Sweden) 1890:CBD incision w/ stone removalCBD incision w/ stone removal

Late 1980’s: Laparoscopic approachLate 1980’s: Laparoscopic approachPoint of origin:Point of origin:

S d (G llbl dd )S d (G llbl dd )Secondary (Gallbladder)Secondary (Gallbladder)Primary (Primary (de novo de novo within biliary tract)within biliary tract)

Time of discovery:Time of discovery:Time of discovery:Time of discovery:Retained: within 2 years of cholecystectomyRetained: within 2 years of cholecystectomyRecurrent: 2 years post cholecystectomyRecurrent: 2 years post cholecystectomyRecurrent: 2 years post cholecystectomyRecurrent: 2 years post cholecystectomy


Etiolog (cont)Etiolog (cont)Etiology (cont)Etiology (cont)

Primary CBD stones:Primary CBD stones:SouthSouth--east asian populationseast asian populationsAssociated with stasis and infectionAssociated with stasis and infectionAssociated with stasis and infectionAssociated with stasis and infectionBrown pigment typeBrown pigment typeSoft and easy to crumbleSoft and easy to crumble

Bilia stasisBilia stasisBiliary stasis:Biliary stasis:Biliary strictureBiliary stricturePapillary stenosisPapillary stenosisSphincter of Oddi dysfunctionSphincter of Oddi dysfunction

Positive biliary cultures:Positive biliary cultures:

Stasis → Bacterial glucoronidases → Deconjugation of bilirubin diglucuronide &precipitation of bilirubin as its calcium salt


I iti l t ti d di iI iti l t ti d di iInitial presentation and diagnosisInitial presentation and diagnosis

10% pts for Lap chole10% pts for Lap choleJaundiceJaundice

EpisodicEpisodicppPainfulPainfulLightening of stoolsLightening of stoolsDarkening of urineDarkening of urineggT.bili > 3.0T.bili > 3.0↑↑ LFT’sLFT’s

Cholangitis: Charcot’s triadCholangitis: Charcot’s triadggFever, jaundice, and RUQ painFever, jaundice, and RUQ pain

Ultrasound: CBD dilationUltrasound: CBD dilation58% vs 1% when CBD > 5mm58% vs 1% when CBD > 5mm


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


CholedocholithiasisCholedocholithiasisCholedocholithiasisCholedocholithiasis

Pre, Intra or Post operative Pre, Intra or Post operative High suspicionHigh suspicion

Preoperative ERCP and sphincterotomyPreoperative ERCP and sphincterotomyPreoperative ERCP and sphincterotomyPreoperative ERCP and sphincterotomyLaparoscopic cholecystectomy with intraoperative Laparoscopic cholecystectomy with intraoperative cholangiogram and CBD exp.cholangiogram and CBD exp.L i h l t t ith i t tiL i h l t t ith i t tiLaparoscopic cholecystectomy with intraoperative Laparoscopic cholecystectomy with intraoperative cholangiogram and postoperative ERCP and cholangiogram and postoperative ERCP and sphincterotomysphincterotomyCh l t t d CBD l tiCh l t t d CBD l tiCholecystectomy and CBD explorationCholecystectomy and CBD exploration

Transduodenal sphincteroplastyTransduodenal sphincteroplastyCholedochoCholedocho--duodenostomyduodenostomyCholedochoCholedocho--jejunostomyjejunostomy


ImagingImagingImagingImaging

Ultrasound: Ultrasound: ID of CBD stones in 60 to 70% positive casesID of CBD stones in 60 to 70% positive cases

MRCP:MRCP:MRCP:MRCP:95% sensitive, 89% specific95% sensitive, 89% specificAvoids ERCP in > 50% moderate risk ptsAvoids ERCP in > 50% moderate risk pts

EUSEUSEUS:EUS:88% sensitive, 90% specific88% sensitive, 90% specificNo instrumentation @ sphincter of OddiNo instrumentation @ sphincter of Oddi@ p@ pDecreased risk of pancreatitisDecreased risk of pancreatitisLimited availabilityLimited availability


ERCPERCPERCPERCP

Diagnostic and TherapeuticDiagnostic and TherapeuticEndoscope into 2Endoscope into 2ndnd portion of duodenumportion of duodenumpp ppPapilla visualized at 12 or 1 o’clock Papilla visualized at 12 or 1 o’clock

Small nubin across semicircular foldsSmall nubin across semicircular foldsSmall nubin across semicircular foldsSmall nubin across semicircular foldsSoft reticulated area at tip = papillary orificeSoft reticulated area at tip = papillary orifice

Cannulation of orificeCannulation of orificeCannulation of orificeCannulation of orificeFluoroscopyFluoroscopyCBD orifice at 11 o’clockCBD orifice at 11 o’clockCBD orifice at 11 o clockCBD orifice at 11 o clockPancreatic duct orifice at 1 to 2 o’clockPancreatic duct orifice at 1 to 2 o’clock


ERCPERCPERCPERCP

CBD cannulation via guidewireCBD cannulation via guidewireSphincterotomySphincterotomy

Electrosurgical division of papillaElectrosurgical division of papillaElectrosurgical division of papillaElectrosurgical division of papillaStone retrieval:Stone retrieval:

Balloon sweepBalloon sweepppBasketBasketCrushing techniqueCrushing technique

Strictures:Strictures:Strictures:Strictures:Cytologic brushingsCytologic brushingsBalloon dilationBalloon dilationStent placementStent placement


ERCPERCPERCPERCP

ComplicationsComplicationsAcinarization or Rupture of small ductulesAcinarization or Rupture of small ductules

Pancreatitis: contrast extravasation into ductPancreatitis: contrast extravasation into ductPancreatitis: contrast extravasation into ductPancreatitis: contrast extravasation into ductCholangitis: contrast into proximal biliary treeCholangitis: contrast into proximal biliary tree

Duodenal perforationDuodenal perforationR i l f i i l iR i l f i i l iRetroperitoneal or free intraperitoneal airRetroperitoneal or free intraperitoneal airEmergency surgery Emergency surgery

BleedingBleedingggEpinephrineEpinephrineElectrocoagulationElectrocoagulationBalloon tamponadeBalloon tamponadeBalloon tamponadeBalloon tamponadeArteriographic embolization of GDAArteriographic embolization of GDA


D ctal imagingD ctal imagingDuctal imagingDuctal imaging

Ch l hCh l hCholangiography:Cholangiography:PercutaneousPercutaneous

Insertion of catheter into cystic duct through a 14 Insertion of catheter into cystic duct through a 14 gauge IV needle/cathetergauge IV needle/cathetergauge IV needle/cathetergauge IV needle/catheter

PortalPortalCatheter introduced through port and into cystic Catheter introduced through port and into cystic ductduct

I i hI i hIntraoperative sonographyIntraoperative sonographyUS transducer inserted through 10mm portUS transducer inserted through 10mm portDirect contact with tissuesDirect contact with tissuesReal time sonographic imagesReal time sonographic imagesReal time sonographic imagesReal time sonographic imagesExpensiveExpensiveNot commonly usedNot commonly used


Cholangiog amCholangiog amCholangiogramCholangiogram


Access to CBDAccess to CBDAccess to CBDAccess to CBD

TranscysticTranscysticSize of cystic ductSize of cystic ductSite of insertion into CBDSite of insertion into CBDSize and location of stonesSize and location of stonesSize and location of stonesSize and location of stones

CholedochotomyCholedochotomyDissection of anterior wallDissection of anterior wallLongitudinal incisionLongitudinal incisionLongitudinal incision Longitudinal incision

TransduodenalTransduodenalSphincterotomySphincterotomySphincteroplastySphincteroplasty

Ch l d hCh l d hCholedochoscopyCholedochoscopyCBD dilation neededCBD dilation needed

OverOver--thethe--wire dilatorswire dilatorsPneumatic dilatorsPneumatic dilatorsPneumatic dilatorsPneumatic dilators


FactorFactor TranscysticTranscystic CholedochotomyCholedochotomy

One stoneOne stone ++ ++

Factors influencing approach to the Common Bile Duct

One stoneOne stone ++ ++Multiple stonesMultiple stones ++ ++Stones < 6mmStones < 6mm ++ ++Stones > 6mmStones > 6mm -- ++IntraIntra--hepatic stoneshepatic stones -- ++Cystic duct < 4mmCystic duct < 4mm -- ++Cystic duct > 4mmCystic duct > 4mm ++ ++CBD < 6mmCBD < 6mm ++ --CBD > 6mmCBD > 6mm ++ ++CBD > 6mmCBD > 6mm ++ ++CD entrance: lateralCD entrance: lateral ++ ++Entrance: posteriorEntrance: posterior -- ++Entrance: distalEntrance: distal -- ++Mildly inflamedMildly inflamed ++ ++Markedly inflamedMarkedly inflamed ++ --Suturing: poorSuturing: poor ++ --Suturing: goodSuturing: good ++ ++


T ansc stic e plo ationT ansc stic e plo ationTranscystic explorationTranscystic explorationLaparoscopic vs OpenLaparoscopic vs OpenLaparoscopic vs OpenLaparoscopic vs Open

Stones larger than duct Stones larger than duct →→ DilatationDilatationIrrigationIrrigationggFluoroscopic wire basketFluoroscopic wire basket

Stones smaller than 2 to 4 mmStones smaller than 2 to 4 mmClockwise rotation while retracting basketClockwise rotation while retracting basketCare not to pull stones into hepatic ductsCare not to pull stones into hepatic ducts

E d i hE d i hEndoscopic approachEndoscopic approachCholedochoscope basketingCholedochoscope basketing

Long spiraling medially inserting cystic ductLong spiraling medially inserting cystic ductLong, spiraling, medially inserting cystic ductLong, spiraling, medially inserting cystic ductCholedochotomyCholedochotomy


CholedochotomCholedochotomCholedochotomyCholedochotomy

Laparoscopic vs OpenLaparoscopic vs OpenLarge stones: > 1cmLarge stones: > 1cmAnterior wall dissection 1 Anterior wall dissection 1 –– 2 cm distance2 cm distanceStay sutures bilaterallyStay sutures bilaterallyVascular supply @ 3 and 9 o’clockVascular supply @ 3 and 9 o’clockLongitudinal incision anterior aspectLongitudinal incision anterior aspecto g tud a c s o a te o aspecto g tud a c s o a te o aspectCholedochoscope insertedCholedochoscope insertedIrrigation, basket retrieval, lithotripsyIrrigation, basket retrieval, lithotripsy12 or 14 Fr T12 or 14 Fr T--tube positionedtube positioned12 or 14 Fr T12 or 14 Fr T tube positionedtube positionedCBD closure over TCBD closure over T--tubetubePrimary closure of CBDPrimary closure of CBDCompletion cholangiogramCompletion cholangiogramCompletion cholangiogramCompletion cholangiogram


Open CBD explorationexploration

T-tube placement


I igation techniq esI igation techniq esIrrigation techniquesIrrigation techniques

Very small stones < 3mm Very small stones < 3mm SludgeSludgeSludgeSludgeSphincter spasmSphincter spasm

Transcystic flushing Transcystic flushing →→ debris clearancedebris clearanceIV glucagon IV glucagon →→ ↓↓ sphincter pressure sphincter pressure Fluoroscopic monitoringFluoroscopic monitoringFluoroscopic monitoringFluoroscopic monitoring


Balloon techniq esBalloon techniq esBalloon techniquesBalloon techniques

4 Fr Fogarty balloon 4 Fr Fogarty balloon cathetercatheterAdvanced intoAdvanced intoAdvanced into Advanced into duodenumduodenumPositioned in distal CBDPositioned in distal CBDInflated balloon s eepInflated balloon s eepInflated balloon sweep Inflated balloon sweep removes stonesremoves stones

For intraFor intra--hepatic stoneshepatic stonesCombined with Combined with choledochoscopecholedochoscopecholedochoscopecholedochoscope


Basket techniq esBasket techniq esBasket techniquesBasket techniques

Basket positioned at Basket positioned at proximal CBDproximal CBDOpened slowlyOpened slowlyOpened, slowly Opened, slowly advanced to distal CBDadvanced to distal CBDSlowly withdrawn while Slowly withdrawn while closing wiresclosing wiresclosing wiresclosing wiresStone capture ID’d Stone capture ID’d when wires fail to closewhen wires fail to close

Avoid capture of papilla Avoid capture of papilla of Vaterof Vater


Othe techniq esOthe techniq esOther techniquesOther techniques

Stone forcepsStone forcepsLithotripsyLithotripsy

Mechanical (crushing technique)Mechanical (crushing technique)Mechanical (crushing technique)Mechanical (crushing technique)ExtraExtra--corporeal shock wave (electromagnetic)corporeal shock wave (electromagnetic)IntraIntra--corporeal (laser)corporeal (laser)

Percutaneous radiologicPercutaneous radiologicPercutaneous radiologicPercutaneous radiologicDissolution (chemical infusion)Dissolution (chemical infusion)

MonooctanoinMonooctanoinMethylMethyl terttert buthyl ether (MBTE)buthyl ether (MBTE)Methyl Methyl terttert--buthyl ether (MBTE)buthyl ether (MBTE)

Ursodeoxycolic acid Ursodeoxycolic acid PreventionPrevention


D ainage p oced esD ainage p oced esDrainage proceduresDrainage procedures

Indications:Indications:Multiple CBD stonesMultiple CBD stonesMultiple CBD stonesMultiple CBD stonesRecurrent choledocholithiasisRecurrent choledocholithiasisUnsuccessful sphincterotomyUnsuccessful sphincterotomyUnsuccessful sphincterotomyUnsuccessful sphincterotomyImpacted large CBD stonesImpacted large CBD stonesMarkedly dilated CBDMarkedly dilated CBDMarkedly dilated CBDMarkedly dilated CBD


Choledochod odenostomCholedochod odenostomCholedochoduodenostomyCholedochoduodenostomy

Side to side biliarySide to side biliary--enteric enteric bypassbypassSimpler and saferSimpler and saferCBD t l t 1CBD t l t 1CBD at least 1cm CBD at least 1cm diameterdiameterNot when suspected Not when suspected duodenal obstructionduodenal obstructionduodenal obstructionduodenal obstructionComplications:Complications:

StrictureStricture“Sump syndrome”“Sump syndrome”p yp y

Food and debris b/w stoma Food and debris b/w stoma and papillaand papillaBiliary contaminationBiliary contaminationCholangitis, biliary cirrhosisCholangitis, biliary cirrhosis


T ansd odenal sphincte oplastT ansd odenal sphincte oplastTransduodenal sphincteroplastyTransduodenal sphincteroplasty

Impacted ampullary stoneImpacted ampullary stone22ndnd portion duodenumportion duodenum11 o’clock incision11 o’clock incision11 o clock incision11 o clock incision“Cut and sew” “Cut and sew” Pancreatic duct @ 3 to 4 Pancreatic duct @ 3 to 4 o’clocko’clocko clocko clockPreserve duodenal lumenPreserve duodenal lumenPancreatitis:Pancreatitis:

E t i i l tiE t i i l tiExtensive manipulationExtensive manipulationElectrocauteryElectrocauteryAccidental suturing of Accidental suturing of pancreatic duct orificepancreatic duct orificepancreatic duct orificepancreatic duct orifice


E idence based medicineE idence based medicineEvidence based medicineEvidence based medicine

Baker et al: 190 pts w/ CDD & 56 w/ TDSBaker et al: 190 pts w/ CDD & 56 w/ TDSMortality: 5% in both groupsMortality: 5% in both groups

bidi % C 2 % Sbidi % C 2 % SMorbidity: 11% CDD, 21% TDSMorbidity: 11% CDD, 21% TDSRadiologic study: CDD stoma admitted air and Radiologic study: CDD stoma admitted air and barium more often than TDS stomabarium more often than TDS stomabarium more often than TDS stomabarium more often than TDS stoma

Kibria and Hall: 267 pts w/ TDSKibria and Hall: 267 pts w/ TDSMedian followMedian follow--up 12 yrsup 12 yrsp yp y4 pts (1.5%) w/ recurrent CBD stones4 pts (1.5%) w/ recurrent CBD stones4/263 (1.5%) perioperative deaths4/263 (1.5%) perioperative deaths


Choledochojej nostomCholedochojej nostomCholedochojejunostomyCholedochojejunostomy

RouxRoux--enen--Y Y Reduces reflux of Reduces reflux of gastric content into gastric content into biliary treebiliary treeEndEnd--toto--sidesideSideSide--toto--sidesideComplications:Complications:

StrictureStrictureBile leakageBile leakage


S mmaS mmaSummarySummary

Multidisciplinary approach to CBD stonesMultidisciplinary approach to CBD stonesPrePre--operative identification based on riskoperative identification based on riskPrePre operative identification based on risk operative identification based on risk factorsfactorsLaparoscopic CBD exploration is safe andLaparoscopic CBD exploration is safe andLaparoscopic CBD exploration is safe and Laparoscopic CBD exploration is safe and carries low morbidity and mortality ratecarries low morbidity and mortality rateS i d t iS i d t iSurgeon experience determines:Surgeon experience determines:

Lap vs Open approachLap vs Open approachType of drainage procedure if necessaryType of drainage procedure if necessary


Ans e sAns e sAnswersAnswers

1.1. CC22 DD2.2. DD3.3. AA

EE4.4. EE5.5. CC


Documents

CBD stones.ppt - SUNY Downstate Medical CenterTitle Microsoft PowerPoint - CBD stones.ppt [Compatibility Mode] Author aleybeng Created Date 7/29/2008 11:24:21 AM