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General Surgery
Choledocholithiasis and Cholangitis
Built from Maingot's Abdominal Operations
What’s inside
16 sections · 181 slides
Overview
- Scope of this presentation
Classification and Epidemiology
Where bile duct stones come from, and how common they are
- Anatomy of the biliary tree
- Lower bile duct and the duodenum
- 15%
- Cost of gallstones and frequency of duct stones
- Secondary and primary bile duct stones
- Secondary stones and how cholesterol stones form
- Risk factors for cholesterol gallstones
- Black pigment and primary brown pigment stones
- Bacteria in stone formation and intrahepatic stones
- Pathogenesis of intrahepatic stones
- Controversy over the role of parasites
Clinical Presentation and Natural History
From a silent stone to sepsis and cirrhosis
- Silent stones and the symptoms they cause
- Complications of the clinical course
- Bacterial biofilm on bile duct stones
- From obstruction to bacterial sepsis
- Natural history of an untreated duct stone
- Physical examination findings
- Blood tests in choledocholithiasis
- Other laboratory clues and their limits
Three Clinical Windows
Duct stones are met before, during or after gallbladder surgery
- Three settings in which duct stones are met
- Why the three windows matter
Preoperative Assessment
Predicting which patient actually harbours a duct stone
- Limits of clinical diagnosis
- Risk factors and independent predictors
- Transcutaneous ultrasound
- Ultrasound and duct dilatation as predictors
- Gallbladder stone size as a predictor
- Predictive values of ultrasound and blood tests
- Combining clinical, laboratory and ultrasound findings
- Treatment pathway for suspected duct stones before surgery
- Reading the preoperative algorithm
Endoscopic Retrograde Cholangiopancreatography
Diagnosis and stone clearance through the mouth
- Development of ERCP
- What ERCP is
- Accuracy of ERCP for duct stones
- Stone in the lower bile duct seen at cholangiography
- Reading the cholangiogram
- Diagnosis and treatment in one sitting
- Stone extraction seen through the endoscope
- Balloon sweep of a stone out of the bile duct
- Sphincterotomy
- Balloon sphincteroplasty
- Choosing between a basket and a balloon
- Difficult extraction and abandoned dissolution therapy
- Mechanical lithotripsy
- Results and limits of mechanical lithotripsy
- Intraductal shock wave lithotripsy
- Safety devices and availability
- Results of electrohydraulic lithotripsy
- Extracorporeal shock wave lithotripsy
- Other shock wave experience
- Large-balloon dilatation of the lower bile duct
- Escalating treatment for a difficult duct stone
- Temporising with drainage and stents
- Long-term stenting as a definitive plan
Complications of ERCP
A safe procedure with well-defined, occasionally lethal risks
- Mortality after ERCP and how to read the figures
- 0.3-0.6%
- Prophylactic antibiotics before ERCP
- Post-ERCP pancreatitis: definition and risk factors
- The highest-risk group and how to protect it
- Drug prophylaxis against post-ERCP pancreatitis
- Nitrates and pancreatic stents
Imaging Before Intervention
Computed tomography, MRCP, endoscopic ultrasound and the percutaneous route
- Rationale for imaging before ERCP
- Computed tomography for duct stones
- Computed tomography compared with endoscopic ultrasound
- Principle of magnetic resonance cholangiopancreatography
- Duct stones on magnetic resonance cholangiopancreatography
- Capability of modern MRCP
- Reported accuracy of MRCP
- Limitations of MRCP and of ERCP
- Endoscopic ultrasound
- Safety and accuracy of endoscopic ultrasound
- Endoscopic ultrasound compared with MRCP
- Percutaneous transhepatic cholangiography
- Percutaneous stone removal
- Transhepatic cholangioscopy and lithotripsy
Cholecystectomy After Duct Clearance
Does the gallbladder still have to come out?
- Argument for removing the gallbladder
- Concern about long-term cancer risk
- Evidence for leaving the gallbladder in place
- Longer follow-up and gallbladder status
- Practical position on cholecystectomy after duct clearance
Stones Found at Operation
Cholangiography, ultrasound and duct exploration during cholecystectomy
- Three groups arriving in the operating room
- Intraoperative cholangiography
- Fluoroscopy and the accuracy of laparoscopic cholangiography
- Routine versus selective cholangiography
- Intraoperative ultrasound
- Natural history of stones found at cholangiography
- Implication for treating a positive cholangiogram
- Treatment pathway for duct stones found at cholecystectomy
- Reading the intraoperative algorithm
- Open common bile duct exploration
- Place of open exploration today
- Rise and results of laparoscopic duct exploration
- Transcystic and transductal access to the duct
- Opening and clearing the duct laparoscopically
- Instruments and closure of the choledochotomy
- T-tube compared with primary closure
- When laparoscopic duct exploration fails
- Intraoperative ERCP
- Results of intraoperative ERCP
- Arguments for intraoperative rather than postoperative ERCP
Stones After Cholecystectomy
Retained and recurrent duct stones
- First-line treatment after cholecystectomy
- Retained stones after gallbladder removal
- Reading this cholangiogram
- Options when ERCP is not possible
Surgical Biliary Drainage
Sphincteroplasty, choledochoduodenostomy and choledochojejunostomy
- Indications for a surgical drainage procedure
- Three surgical drainage operations
- Indications for transduodenal sphincteroplasty
- Exposing the ampulla for sphincteroplasty
- Completing the sphincteroplasty
- Outcomes after transduodenal sphincteroplasty
- Origins and indications of choledochoduodenostomy
- Planning a choledochoduodenostomy
- Technique of choledochoduodenostomy
- Morbidity, mortality and cholangitis after the join
- Sump syndrome
- Preventing sump syndrome
- Other complications and long-term results
- Ten-year comparison of the two duct-widening operations
- What symptoms after the join meant
- A second comparison of the two operations
- Choledochojejunostomy
- Outcomes of the duct-to-jejunum join
- Arguments for and against stenting a biliary anastomosis
- Results without stents and what predicts failure
- Laparoscopic and robotic drainage procedures
- Summary of choledocholithiasis management
Cholangitis
Infected bile behind a blocked duct
- Definition of cholangitis and the defences it defeats
- Loss of defence when the duct is blocked
- From rising duct pressure to septicaemia
- Which obstructions cause cholangitis
- Other causes of cholangitis
- Organisms cultured in cholangitis
- Charcot's triad and Reynold's pentad
- Examination and laboratory findings
- Imaging in suspected cholangitis
- Initial supportive treatment
- Choice of antibiotics
- Duration of antibiotic treatment
- Drainage as the mainstay of treatment
- Endoscopic drainage as first choice
- Endoscopic compared with surgical decompression
- Choosing the endoscopic technique
- Percutaneous and surgical drainage in cholangitis
- Cholecystectomy after an attack of cholangitis
- Where cholecystectomy does not help
Hepatolithiasis
Stones formed in the ducts inside the liver
- Definition and changing pattern of hepatolithiasis
- ~1%
- Causes and stone composition
- Clinical course and cancer risk
- Diagnosis of hepatolithiasis
- Principles and goals of treatment
- Hepatic resection for localised disease
- Effect of duct stricture on results of hepatectomy
- Limits of resection and clearance rates
- Hepaticojejunostomy and building an access point
- Percutaneous choledochoscopic stone removal
- Other percutaneous and laparoscopic results
- North American experience and outlook
Key Points
What to carry away from this topic
- Key points: the stones themselves
- Key points: making the diagnosis
- Key points: treatment
- Key points: cholangitis and liver stones
References
Sources cited in this topic
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- Maingot's Abdominal Operations, 12th Edition