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Biliary stricture with stones

Biliary stricture with stones. Mathew Philip PVS Institute of Digestive Diseases Kochi. Standard therapy for CBD stones . ERC with sphincterotomy and stone extraction 85% to 90% of CBD stones can be removed with Dormia basket or balloon catheter.

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Biliary stricture with stones

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  1. Biliary stricture with stones Mathew Philip PVS Institute of Digestive Diseases Kochi

  2. Standard therapy for CBD stones • ERC with sphincterotomy and stone extraction • 85% to 90% of CBD stones can be removed with Dormia basket or balloon catheter

  3. Difficult common bile duct stones • Not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon

  4. CBD stone removal - Challenges • Large stones (> 15 mm diameter) • Impacted stones • Intra hepatic stones • Bile duct stricture • Narrow distal CBD • Poorly expandable common bile duct • Difficult anatomy

  5. Bile duct stricture with stones • True strictures with stones

  6. Bile duct stricture with stones • Poorly expandable CBD with stones Chi-Liang Cheng et al WJG 2012

  7. Management • Endoscopic • ESWL • Surgery

  8. Endoscopic techniques • ERC/ ES / Mechanical Lithotripsy • Balloon dilatation followed by lithotripsy • Multiple Stents followed by lithotripsy later • Cholangioscopy – Holmium laser lithotripsy/ EHL • Permanent biliarystenting

  9. Biliarystenting • Potential definitive treatment in selected elderly patients who are poor candidates for surgery • Endoprosthesismay reduce stone size • May allow later clearance of unextractable stones • Problems - cholangitis

  10. ESWL • Accepted modality for large CBD stones • NBD and ESWL followed by stone removal and stenting Tandan M et al J GastroenterolHepatol. 2009

  11. ESWL Pre ESWL Post ESWL Tandan M et al J GastroenterolHepatol. 2009

  12. Surgery • Lap vs. open • Definitive treatment for stricture • When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones

  13. CBD stricture with stones Factors influencing treatment • Associated cholangitis • High risk patients • Anatomical abnormality • GB in situ with stones • Intra hepatic stones(RPC)

  14. CBD stones with strictures Elderly /high risk patients Cholangitis Young /stable /GB in situ ERC /ESWL/Lithotripsy/Stent ERC /NBD /Stent Surgery Surgery ERC /lithotripsy/Stent

  15. Thank you

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