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,*,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,Click to edit Master title style,Click to edit Master text styles,Second level,Third level,Fourth level,Fifth level,*,“,More Than You Bargained For,”,Dr Asif Khan,Case 1,38 y/o female.,Rt upper quadrant pain and vomiting, deranged LFTs (obstructive picture) PMH includes,ERCP,Two stones 8 and 10mm identified but unable to remove, stent was placed and sphincterotomy performed.,Laparoscopic Cholecystectomy,MRCP 2007,Clinical Exam,Afebrile, hemodynamically stable.,Scleral icterus.,Abdomen soft, mildly tender , negative Murphys sign.,No rebound tenderness/guarding, no masses appreciated.,Blood Results:,WBC 4.6 x 10,9,/L (4-10 10,9,/L ),AST 258 IU/L (14-54 ) ; ALT 352 IU/L (14-54),Billirubin 77 umol/L (3.4-20.5),Alkaline phosphatase 258 IU/L ( 42-121),INR 1.1,Investigations,U/S Dilated CBD (14mm) containing two stones, one 13 mm.,ERCP attempted,Blocked stent , dilated CBD , two large stones 1cm in size, small stones and sludge. Stent changed and surgical intervention suggested as stones unretrievable via ERCP,MRCP planning pre IR,Confirms ductal stones and dilated ducts,Prominent ducts especially those beyond the stones in the right radicular duct system.,Modified Burhenne PTC technique - feasible,Investigations,MRCP; to assess interventional approach,Percutaneous Approach,Right PTC: Access ducts beyond incarcerated stone -a pre-requisite,Stone,Management,PTC and cannulation guide wire technique,Modified “ Burhenne” technique,Over the wire Fogarty Balloon - push,Stones were pushed into the duodenum and stent inserted. CBD was cleared.,PTC: Right needle access to biliary ducts - fluoroscopy,Stone,Over the wire Fogarty Balloon 5 Fr,“ Burhenne” - push,Post Procedure,Post interventional radiology,Patient made good recovery,Discharged home no further episodes.,LFTs normal.,Case 2,72 y/o female.,Admitted with RUQ pain , fever and jaundice.,Clinical picture of Cholangitis treated with IV antibiotics ,fluid resuscitation and analgesia.,Recurrent admission for symptomatic choledocholithiasis and repeated ERCP attempts,ERCP 1-failed,ERCP 2-failed,ERCP 3-failed,Investigations,US Abdomen Multiple gall stones and CBD diameter 1.1 cm.,MRCP - Gall stones and multiple ductal stones , dilated CBD.,ERCP - Unable to remove stones and stent was inserted.,MRCP 2,Management,Open cholecystectomy and CBD Exploration,performed.,Findings: More than 12 big and small stones removed from CBD. Normal anatomy.,Duct clear on choledochoscopy.,T tube cholangiogram Day 7 post op,Findings: Two retained stones in Rt,duct system.,T tube cholangiogram,Management,Percutaneous approach to stone clearance,Modified “Burhenne technique” push.,T tube track.,Duct cannulation per T tube track. Catheter wire contrast technique,Over the wire Fogarty Balloon stone pull - push to duodenum.,Pull,Push,External Drain After Modified Burhenne Technique,Management,Overnight external drain,Check cholangiogram following morning.,Findings: Duct clear. External drain removal,LFTS normal.,Discussion,Last 30 years have seen major advances in the management of gallstone disease, which in the U.S. alone, costs over 6 billion dollars per annum to treat.,In patients who have cholecystectomy for gallbladder stones, approximately 10% to 18% also have common bile duct (CBD) stones.,Pathogenesis,CBD Stones,Primary CBD stones,Bilirubin is dominant component.,Secondary CBD Stones,Descend from the gallbladder,Cholesterol is dominant component.,Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 page,Clinical Presentation,Asymptomatic,Symptomatic,Biliary colic with pale stools, dark-colored urine and pruritis.,Cholangitis or gallstone pancreatitis.,Acute obstructive cholangitis is a life-threatening complication caused by an infection secondary to biliary obstruction.,Diagnosis,Investigation,Sensitivity,Specificity,US,25-82%,56-100%,EUS,95 %,95-98 %,MRCP,95 %,97 %,CT,87 %,97 %,Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages,Management Options CBD Stones,Open cholecystectomy + CBD exploration.,ERCP + Endoscopic Sphincterotomy (followed by cholecystectomy most frequently used).,Laparoscopic cholecystectomy + Laparoscopic CBD exploration in specialized centers.,Choledochoscopy at laparoscopy or percutaneous choleydochoscopy or choleydochoscopy through,T tube.,CBD stones,ERCP has become a popular technique to clear CBD stones.,Currently in the laparoscopic era studies have shown that laparoscopic treatment of CBD stones is possible and is potentially as effective as ERCP.,This is most commonly done by a transcystic approach, though evidence of success in large volume cohorts with a more technically demanding laparoscopic Choledochotomy is emerging .,(Fletcher 1994 ;Cuschieri 1996; Lezoche 1996),ERCP,Despite the fact that therapeutic ERCP is increasingly being used to manage biliary tract diseases, the procedure remains compounded by two persistent problems: failure of successful biliary cannulation, and post ERCP-pancreatitis (PEP).,PTC and guide-wire cannulation has been proposed as a simple way to avoid PEP.,Lella F, Bagnolo F, Colombo E, Bonassi U. A simple way of avoiding post- ERCP pancreatitis. Gastrointest Endosc 2004; 59: 830-834.,Bailey AA, Bourke MJ, Williams SJ, et al. A prospective randomized trial of cannulation technique in ERCP: Effects on technical success and post-ERCP pancreatitis. Endoscopy 2008; 40: 296-301.,Management CBD Stones,Burhenne technique,Treatment of retained CBD stones found on T tube cholangiography,Technique modified by ERCP and sphincterotomy practice,Percutaneous extraction or duodenal deposition under fluoroscopic control. Catheter wire contrast - balloon,Approach depends on ? +/- sphincterotomy,Percutaneous sphincteroplasty - alternative,British Journal of SurgeryVolume 78 Issue 8,Pages959-960,Vanderburgh L, Yeung EY, Ho CS. Radiologic management of problematic biliary calculi.,Sem Intervent Radiol,1986; 13:69 77,Management CBD Stones,Percutaneous therapy is the option before resorting to surgery.,Fluoroscopically-guided extraction of resident calculi through a sinus tract,T,tube (Kher tube) is a well-established procedure.,If no,T,tube is in place, a transhepatic approach may be attempted.,“Rendez-vous”technique. Combined percutaneous IR and endoscopic ERCPprocedure,Burhenne HJ. Percutaneous extraction of retained biliary tract stones: 661 patients.,AJR,1980,Rendez-vous guide-wire technique,The PTC guide-wire technique seems to reduce the incidence of post-ERCP pancreatitis in the elderly as compared to the conventional contrast technique, but does not appear to improve the primary success rate for biliary cannulation during ERCP in this population.,Lazaraki G, Katsinelos P. Prevention of post- ERCP pancreatitis: an overview. Ann Gastroenterol 2008; 21: 27-38.,Adjuvant Techniques with ERCP+ES,Laparoscopic CBD exploration/Choleydochoscopy.,Mechanical lithotripsy,LASER lithotripsy,Electrohydraulic lithotripsy,ESWL,Chemical contact dissolution therapy,Take Home Message,CBD Stones associated with 10-18 % of patients,undergoing cholecystectomy.,Advanced endoscopic & laparoscopic,techniques have revolutionized management.,PTC and IR (guide wire cannulation) are still successful techniques for retained stones.,
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