Choledocholithasis
DEFINITION
Refer gallstones.
Management mainly discussed here.
top D I A B M
I M home
INCIDENCE
Occurs in ~10% of patients undergoing cholecystectomy.
Incidence increases with age; 30-50% of pts >70 yrs.
top D I A B M
I M home
AETIOLOGY
Refer gallstones card.
top D I A B M
I M home
BIOLOGICAL BEHAVIOUR
Pathophysiology
May follows cholelithiasis.
Stone impacted in gb mouth may migrate down cystic duct and get
stuck in
ductal system.
Can also form de novo in ducts (esp pigment stones).
Complications
Pancreatitis
Jaundice and cholangitis
top D I A B M
I M home
MANIFESTATIONS
5-10% may be completely asymptomatic.
Local
May have history of cholelithiasis.
Pain, similar to cholelithiasis pain.
Jaundice.
Systemic
Vomiting, nausea.
Not feverish / septic.
Signs
Refer cholelithiasis
top D I A B M
I M home
INVESTIGATIONS
Haematology
Routine bloods.
Elevated WCC suggestive of cholecystitis
or cholangitis.
Biochemistry
LFTs - obstruction of the common bile duct by a stone elevates GGT
and ALP.
Bilirubin may be raised.
Amylase - may be elevated for ~24 hours after stone passage or in
pancreatitis
Imaging
USS
Bright echo with acoustic shadowing if stones found.
Ducts may be dilated.
False negative in ~5% of examinations
ERCP
MRCP
top D I A B M
I M home
MANAGEMENT
Preoperative Risk Stratification
Enlarged CBD, CBD stone suggested, gallstone pancreatitis,
elevated liver enzymes = higher risk
- if 2 or more enzymes up = greater chance of CBD stones.
Pre-op Options
Some surgeons choose to image-confirm (eg MRCP) and/or clear ducts
by ERCP prior to surgery.
- ERCP success rate 80-90%; normal in 40% with suspected stones.
- 5-15% morbidity; 0-2% mortality; significant costs; greater inpt
stay length.
Intra-Op Option
ICC and clearing duct during surgery.
Lap CBD exploration has not been widely embraced like lap chole
- barriers include expertise, time constraints, inadequate
equipment.
IOC
Identifies stones, anatomy and bile duct injuries.
Indicated for CBD stones and unclear anatomy.
- should see both hepatic ducts, CBD, dye into duodenum.
- if can't see proximal structures, Trendelenburg and morphine
sulfate for SOO spasm.
--> if still no proximal structures, consider a proximal injury
and consider opening the patient to investigate.
- if no flow to duodenum, can give glucagon to relax the sphincter.
Sometimes routine to decrease incidence of CBD transection.
When used selectively, for history of jaundice, pancreatitis,
elevated LFTs.
Stone Found?
Either abort and get post-op ERCP or proceed with CBDE.
Small stones 2-3mm can be forcefully flushed with saline after
glucagon administration.
Transcystic approach = less invasive.
Fluoroscopic guidance = less kit than choledochoscopy.
Stone basket (eg zero-tip ureteric stone retrieval basket is quite
nice) into CBD under guidance.
- prefer vs balloon as with balloon trawl can drag stones up hepatic
duct, making retrieval difficult.
Cystic duct may need dilation with ureteric bougies if using a
choledochoscope, even up to 7-8mm.
- when using scope, stones generally retrieved via an attached
basket.
Completion cholangiogram.
Secure cystic duct with a PDS endoloop + clips.
Success rate similar to ERCP 70-90%.
Complication rate 0-10%, e.g. cystic stump leaks, bile duct injury
or pancreatitis.
Retained stones in 2-4%
Difficulty?
Commonly occurs if stones are large (>8mm), or cystic duct small
or tortuous.
Then can go for CBD exploration.
Technique of laparoscopic CBD
exploration?
I'd go for an ERCP first and then only do this if no access or
failure.
--> open exploration is now an uncommon procedure.
Avoid if duct <5mm; small.
Stay sutures at 3 and 9 o'clock.
Traction on CBD.
Ductotomy 10-20mm with scissors along vertical axis or anterior
surface.
Flush with large catheter; often clears duct if small mobile stones.
Then pass a balloon catheter, stone basket or choledochoscope
through the ductotomy.
Fluoroscopic guidance.
Ensure complete clearance of the duct.
Can cut the back off the T-tube like a half-pipe.
Close over a T-tube, generally 10-14 Fr, cut to appropriate length,
using interrupted sutures of suitable length.
Completion cholangiogram.
Success rates 80-90%, complication 5-15% as above.
- small risk of bile duct stricture.
Remove T-tube d10 post op, T-tube cholangiogram ensures no further
CBD access needed.
Technique of open exploration?
RUQ incision, wide Kocher mobilization.
As above, but can palpate stones distally and use stone forceps or
balloon catheters to clear duct.
Place one hand on pancreatic head to guide instruments and prevent
CBD injury.
Use a choledochoscope to allow direct vision.
Ensure ampulla open with a Fogarty balloon catheter.
Close over a 14Fr T-tube.
Impacted stones are a challenge rarely encountered.
top D I A B M
I M home