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1、Common Bile Duct Stones-Management Options,解放军324医院肝胆外科张丰深,Gallstones,Incidence 12%men and 24%women(from autopsy study in UK)10-30%of gallstones will become symptomatic(1-2%per year)Incidence of CBD stones found before or during cholecystectomy 12%,Composition,Cholesterol(70-80%)Uncommonly pure chol
2、esterol stones(10%)Most have calcium salts in their centre(90%)and 10%of these have enough calcium to be radioopaquePigment(20-30%)BLACK-secondary stones associated with haemolysis or cirrhosisBROWN-primary stones associated with bile stasis or infection,Shojaiefard A,et al.Various techniques for th
3、e surgical treatment of common bile duct stones:a Meta review.Gastroenterology Research and Practice,2009;1-12,Classification,Primary Stones(5%)Form de novo in CBD Related to biliary stasis and infection Tend to be brown pigment stones Secondary Stones(95%)Formed in gallbladder Tend to be cholestero
4、l stones,Classification,Retained 2yrs post cholecystectomy,Presentation,Incidental findings at cholecystectomy Biliary colic Jaundice Pancreatitis Cholangitis,The 4 main liver enzymes 毛远丽,刘志国,孙志强,等.检验与临床诊断-肝病分册.北京:人民军医出版社,2006:131-210,Risk stratification,Risk stratification,Initial classification of
5、 suspected choledocholithiasis according to Cotton criteria as determined by ERCP and MRCP(Calvo et al,Mayo Clin Proc,2002),Risk Stratification,Predictive scores for each multivariate factor used to produce the scoring system(Menezes et al,BJS,2002),Risk stratification,High risk if-CBD 6mm-2 or more
6、 abnormal LFTs-cholecystitis/pancreatitis?Preoperative ERCP Intermediate risk-MRCP Low risk-USS then LC,Imaging,Plain x-rayUltrasoundCTMRCPERCP,Ultrasound,Most widely used Easy to perform Causes little discomfort Avoid irradiation and contrast media High reliability of diagnosing gallbladder stones(
7、95%)Variable reliability of detecting CBD stones 23%-80%depends on body habitus and experience of sonographer,Endoscopic ultrasound,Studies using EUS to evaluate prior to ERCP Avoids cannulation of papilla and avoids the risk of cholangitis and pancreatitisSensitivity 93%Specificity 97%Approaches ER
8、CP with experience,CT,Sensitivity for CBD stones causing obstructive jaundice 75%Stones usually isodense with bile(not useful for assessment of cholelithiasis)CT cholangiogram unsuitable in jaundice as contrast not excretedImportant for imaging of pancreas if suspicion of malignant disease and other
9、 abdominal organs,MRCP,Detail now approaches ERCP Technique relies on the principle of imaging fluid columns that are static,better images with dilated ducts and flow artifact can give false positive results Sensitivity 95%Specificity 89%Accuracy 92%,MRCP,Advantages No irradiation Avoids complicatio
10、ns of ERCP in 5%-10%of patients Disadvantages Claustrophobic&noisy Contraindicated if metal implants/foreign bodies Diagnostic only-not therapeutic,ERCP,Considered gold standard for preoperative imaging CBD Both diagnostic and therapeutic,ERCP、取石,Natural history(Tranter,Ann R Coll Surg Engl,2003),Di
11、fficult to predict Prospective study,1000 cases of symptomatic gallstones,73%had features suggestive of CBD stones,but had no CBD stones at OT and considered to have passed the stone spontaneously Cases with cholangitis or jaundice were less likely to pass spontaneously,Primary(common)bile duct ston
12、es,Usually due to ampullary stenosis,diverticula or impaired bile duct motilityOften require choledochojejunostomy(subject to circumstances and patient age)Management with choledochotomy&T-tube drainage alone associated with recurrence rates up to 41%Laparoscopic choledochoduodenostomy-an option for
13、 advanced laparoscopic surgeon,but concerns regarding long term consequences of bilioenteric reflux,Secondary bile duct stones,Found at the time of or within 2 years of cholecystectomy12%cholecystectomies90%have preoperative indications(jaundice,pancreatitis or abnormal LFTs)5%-10%have no pre-op ind
14、ication and are detected at IOC(filling defect,absence of filling terminal segment of CBD or delay/absence of flow into duodenum),The best management of CBD stones is still a matter of debate,ERCP,General agreement ERCP is preferable inPost-cholecystectomy patientsHigh risk surgical patients who sti
15、ll have a gallbladderSevere acute cholangitisSelected patients with acute biliary pancreatitisFailed transcystic exploration with a CBD 8mm,ERCP,Areas of disagreement First line management of CBD stones Preoperative CBD clearance,ERCP,CBD clearance 90%-95%with successful sphincterotomy(papillary dil
16、atation is an alternative)Overall clearance 80%-95%(improves with experience of endoscopist)Major complications in 10%,ERCP complications,Acute(5%)Haemorrhage 1%-6%Acute pancreatitis 1%-19%CholangitisRetroduodenal perforation 1%-2%Failure to clear or access duct 2%-18%Overall procedure mortality 1%3
17、0 day mortality can reach 15%(reflects severity of underlying disease),ERCP complications,MediumRecurrent stones 2%-14%Cholangitis 1%-6%Bacterobilia 60%LateBile duct malignancy 2%(Prat et al,Gastroenterology,1996&Tanaka et al,Gastrointest Endosc,1998),Difficult bile duct stones at ERCP,Stones 15mm I
18、ntrahepatic stones Multiple stones Impacted stones Stone proximal to biliary stricture Tortuous bile duct Disproportionate size of bile duct stone Duodenal diverticulum Bilroth 2 reconstruction Surgical duodenotomy,Adjuvant techniques,Mechanical lithotripsy Extracorporeal shockwave lithotripsy Chemi
19、cal dissolution Successful stone fragmentation has been reported in up to 80%of patients,but major drawback is the need for multiple treatment sessions and repeat ERCP to retrieve stone fragments,ERCP stent insertion,5%of cases where stone extraction fails either a nasobiliary tube or stent should b
20、e inserted for CBD decompression Stents may block after a few months,but bile often drains around stent If surgically unfit can change stents if jaundice recurs Recurrent episodes of cholangitis can lead to secondary biliary cirrhosis in the long term so careful consideration before surgery is total
21、ly discounted,Preoperative ERCP,Eliminates the intraoperative dilemma as to how to manage CBD stonesExposes a number of patients to an unnecessary procedure and associated complicationsSuccessful cannulation of papilla 96.8%with stones cleared in 86%,13%unnecessary ERCP with failure rate 4.5%and mor
22、bidity 2.2%(Hamy,Surg,Endosc,2003)Randomised study has shown no significant advantage for patient treated with preoperative ERCP with sphincterotomy vs open cholecystectomy and CBD exploration(Neoptolemos et al,Br J Surg,1987),Preoperative ERCP,Cholecystectomy should routinely follow clearance of CB
23、D except in those too frail for a general anaesthetic If the gallbladder is left intact it can be expected that 47%of patients will develop at least on recurrent biliary event(Boerma et al,Lancet,2002),Intraoperative ERCP,Described in literature but few centers consider it an appropriate use of reso
24、urces,Postoperative ERCP,Dictated by local expertise and practice Small(5mm)stones found at IOC could be left to pass,follow up to 33 months found 29%developed symptoms and were subsequently managed successfully with ERCP(Ammori et al,Surg Endosc,2000),Laparoscopic transcystic CBD exploration,Fibreo
25、ptic instruments or radiologically guided wire baskets or balloons Two randomised trials have shown 60%-70%of patients are able to have their calculi cleared via the cystic duct(Cuscherieri et al,Surg Endoscopy 1999&Rhodes et al,Lancet 1998)1-2%patients managed without cholangiogram will present wit
26、h a retained stone,Transcystic exploration,Standard dissection to identify cystic duct Cystic duct opened distal to a previously applied clip Milk stones from cystic duct Cholangiogram Assessment of stone and duct size Tiny stones or possible sphincter of oddi spasm try glucagon and flush with salin
27、e then repeat cholangiogram,Transcystic exploration,Nathanson basket fed into CBD(ensure tip of basket well back from tip to avoid duct perforation)Under image intensification tip positioned,basket opened and stone removed If stone impacted can dislodge with 4Fr fogarty catheter or perform choledoch
28、oscopy,Techniques to improve transcystic clearance,Careful dissection of cystic duct/CBD junction Avoidance of spiral valves when entering cystic duct Careful examination of cholangiogram Approach cystic duct from different or extra ports Dilation of cystic duct with a balloon Choledochoscopy via cy
29、stic duct Vary retraction on fundus Cystic duct closure clips or endoloops Subhepatic drainage,Trans cystic exploration success,Stones few in number Small in size(1cm)Situated in the common duct or distal to the cystic duct entry,Choledochotomy preferable if,Large and/or numerous stones Common hepat
30、ic duct or intrahepatic ducts Careful consideration of laparoscopic strategies to be employed,equipment required and adequacy of assistance,Indications for choledochotomy,Unsuccessful transcystic explorationCystic duct diameter smaller than stonesCBD 8mmMultiple large stonesImpacted stones with feat
31、ures of cholangitisAmpullary diverticulum on IOCPrevious bilroth 2 gastrectomyPrevious failed ERCPContraindication to post post-op ERCPERCP unavailable,Laparoscopic choledochotomy,35%of patients transcystic approach fails to clear the CBD Only absolute contraindication in a CBD 8mm Consider that 1/3
32、 stones detected at IOC will pass spontaneously and exploration of a small duct may result in increased morbiditySurgeon must be appropriately trained,Laparoscopic choledochotomy,Deflate duodenum with NGT Extraport to retract duodenum Leave cholangiocatheter in place to prevent deflation of CBD Lapa
33、roscopic knife for choledochotomy Flushing,Fogarty catheter and basket to remove stones Once duct confirmed cleared(choledochoscopy)consider:T tube;primary closure+/-antegrade stent across ampulla;cystic duct tube decompresion,CBD decompression,Controversy over T-tube,antegrade stents,cystic duct st
34、ents or no drainageIf any doubts about free postoperative drainage of bile through ampulla,then decompressMost likely to need decompression if stone was impacted,extensive ampullary monipulation or cholangitisSubhepatic drainage essential,Reasons to consider conversion to open choledochotomy,Unsucce
35、ssful transcystic CBD exploration Unsuccessful laparoscopic CBD exploration Multiple CBD stones(10)Large CBD stones Intrahepatic or proximal duct stones Impacted stones Failed or unavailable ERCP,Open choledochotomy,Successful exploration involves an adequately sized choledochotomy to facilitate rem
36、oval of stones and choledochoscopyIntroduction of choledochoscopy(1970-80s)led to a decline in retained stones from 10%to 1.2%Choledochoscopy allows visualisation of several generations of upper ducts(when dilated)and the ampulla,T-tube,CBD decompressionAllows access to biliary tree for postoperativ
37、e cholangiography and reexploration without the need for reoperation,T-tube complications,Fluid and electrolyte disturbancesBile leak around T-tubeBile leak after removal 1%-19%Silicon coated latex tubes cause less fibrotic response than red rubber tubes,need to stay in longer(4-6weeks)to avoid bili
38、ary peritonitis on removalAdvocated for complicated cases such as cholangitis,pancreatitis or difficult explorationIn the absence of these factors primary closure has been shown to be as safe as T-tube drainage in several randomised trials(De Roover et al,Acta Chir Belg,1989;Sheen-Chen and Chou,Acta
39、 Chir Scand,1990&Williams et al,ANZ J Surg 1994),No single technique will be applicable to the management of all CBD stones,Management of CBD stones,Preoperative ERCP and laparoscopic CBD clearance have equivalent overall outcomes(Rhodes et al,Lancet,1998)ERCP LCBDE CBD clearance 75%-96%90%Morbidity
40、 13%8%Mortality 1%1%Pancreatitis 3%1%(Tranter and Thompson,BJS,2002)Patients who have a transcystic approach have a shorter hospital stay,Options if laparoscopic transcystic exploration fails,Ligate cystic duct,complete cholecystectomy and rely on postoperative ERCP Perform laparoscopic choledochoto
41、my Laparotomy and open CBD exploration,Options if laparoscopic choledochotomy fails,Insert T-tube and extraction of stones after 6 weeksPostoperative ERCPConversion to open CBD exploration,Randomized trial in Brisbane(Nathanson et al,Ann Surg,2005),Trial Randomization,Randomized trial in Brisbane(Na
42、thanson et al,Ann Surg,2005),Randomized trial in Brisbane(Nathanson et al,Ann Surg,2005),Recurrent or retained CBD stones,Recurrent in 10%casesMore common in patients with primary duct stones,CBD 16mm and periampullary diverticulaRetained stones found on T-tube cholangiogram best dealt with by ERCPT
43、akes 6 weeks for tract to mature and allow percutaneous radiologically guided stone extraction or choledochoscopy successful in 95%and carries less risk of pancreatitis or haemorrhage,Cholelithiasis,Suspicion of CBD stones,Selective per-op cholangiogram,No stones,LC,Routine per-op cholangiogram,Rout
44、ine per-op ERCP,CBD stones,CBD stones,EST and duct clearance,LC,LCBDE,OCBDE,Post-opERCP,Failure,Failure,Success,Failure,OCBDE,LCBDE,Failure,Algorithm showing the available strategies for management of common bile duct stones,Shojaiefard A,et al.Various techniques for the surgical treatment of common
45、 bile duct stones:a Meta review.Gastroenterology Research and Practice,2009;1-12-以ERCP为先导,Liu TH,et al.Patient evaluation and management with selective use of MRCP and ERCP before LC.Ann Surg 2001;234(1):33-40,Liu TH,et al.Patient evaluation and management with selective use of MRCP and ERCP before
46、LC.Ann Surg 2001;234(1):33-40,Liu TH,et al.Patient evaluation and management with selective use of MRCP and ERCP before LC.Ann Surg 2001;234(1):33-40,Group 2 patients,Group 1 patients,Group 3 patients,Group 4 patients,TherapeuticERCP,MRCP,LC+IOC,LC,(),(),Liu TH,et al.Patient evaluation and managemen
47、t with selective use of MRCP and ERCP before LC.Ann Surg 2001;234(1):33-40,Liu TH,et al.Patient evaluation and management with selective use of MRCP and ERCP before LC.Ann Surg 2001;234(1):33-40,Liu TH,et al.Patient evaluation and management with selective use of MRCP and ERCP before LC.Ann Surg 200
48、1;234(1):33-40,胆囊结石继发胆总管结石危险度分级解放军第324医院肝胆外科,Gallbladder stones,Low suspicion of CBD stones,Intermediate Suspicionof CBD stones,high suspicion of CBD stones,LC,Lap-IOC,No CBD stones,CBD stones,MRCP,No CBDS,CBDS,Therapeutic ERCP,经胆囊管LCBDE,经胆总管切开LCBDE,Failure,解放军第324医院肝胆外科胆结石微创诊疗流程,Failure,Success,No
49、suspicion of CBD stones,Management of CBDS depends on 总的趋势是无/微创、cost-effective 病人一般情况能否耐受麻醉和复杂操作;胆囊有无结石/胆管病理/CBDS情况/胆胰肠接合部;病人意愿/经济情况;personal experience;equipment availability;time and the availability of other expertise.,后记GBS继发CBDS诊疗的EBM实践,一、GBSCBDS可能性的评估及存在的问题二、何时继续试验？何时治疗？治疗方法选择？三、基于我们临床实践的GBSCB
50、DS预测的方法、进一步的诊疗流程完善,GBSCBDS可能性的评估及存在的问题,灵敏度sen=真阳性率TP=a/(a+c)特异度spe=真阴性率=d/(b+d)假阳性率FP=误诊率=b/(b+d)=1-spe假阴性率FN=漏诊率=c/(a+c)=1-sen患病率pre=(a+c)/N正确性acc=粗符合率=(a+d)/N正确性指标=Youdens index=(sen+spe)-100%值=2(ad-bs)(a+b)(c+d)(a+c)(b+d)0.711.00 很好 0.400.74 一般 0.010.39 不好,GBSCBDS可能性的评估及存在的问题,阳性预测值PV=a/(a+b)PV pr
