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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)

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The management of patients with CBD stone and gallstone

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  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

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