1. “More Than You Bargained For ” Dr Asif Khan

2. Case 1 38 y/o female. Rt upper quadrant pain and vomiting, deranged LFT’s (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

3. Clinical Exam Afebrile, hemodynamically stable. Scleral icterus. Abdomen soft, mildly tender, negative Murphy’s 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

4. 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

5. Investigations MRCP; to assess interventional approach

6. Percutaneous Approach Right PTC: Access ducts beyond incarcerated stone -a pre- requisite Stone

7. 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.

8. PTC: Right needle access to biliary ducts - fluoroscopy Stone

10. Over the wire Fogarty Balloon 5 Fr

11. “ Burhenne” - push

12. Post Procedure Post interventional radiology, Patient made good recovery Discharged home no further episodes. LFT’s normal.

13. 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

14. 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.

15. MRCP 2

16. 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.

17. T tube cholangiogram

18. 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.

20. Pull

21. Push

22. External Drain After Modified Burhenne Technique

23. Management Overnight external drain Check cholangiogram following morning. Findings: Duct clear. External drain removal LFT’S normal.

24. 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.

25. 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

26. 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. Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages doi:10.1155/2009/840208

27. Diagnosis InvestigationSensitivitySpecificity US25-82%56-100% EUS95 %95-98 % MRCP95 %97 % CT87 %97 % Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages

28. Management Options– CBD Stones Open cholecystectomy + CBD exploration. Open cholecystectomy + CBD exploration. ERCP + Endoscopic Sphincterotomy (followed by cholecystectomy – most frequently used). ERCP + Endoscopic Sphincterotomy (followed by cholecystectomy – most frequently used). Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in specialized centers. Laparoscopic cholecystectomy + Laparoscopic CBD exploration – in specialized centers. Choledochoscopy at laparoscopy or percutaneous choleydochoscopy or choleydochoscopy through T tube. Choledochoscopy at laparoscopy or percutaneous choleydochoscopy or choleydochoscopy through T tube.

29. 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)

30. 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.

31. Management – CBD Stones Burhenne technique Burhenne technique Treatment of retained CBD stones found on T tube cholangiography Treatment of retained CBD stones found on T tube cholangiography Technique modified by ERCP and sphincterotomy practice Technique modified by ERCP and sphincterotomy practice Percutaneous extraction or duodenal deposition under fluoroscopic control. Catheter –wire – contrast - balloon Percutaneous extraction or duodenal deposition under fluoroscopic control. Catheter –wire – contrast - balloon Approach depends on ? +/- sphincterotomy Approach depends on ? +/- sphincterotomy Percutaneous sphincteroplasty - alternative Percutaneous sphincteroplasty - alternative British Journal of SurgeryVolume 78 Issue 8, Pages 959 - 960 British Journal of SurgeryVolume 78 Issue 8, Pages 959 - 960 Vanderburgh L, Yeung EY, Ho CS. Radiologic management of problematic biliary calculi. Sem Intervent Radiol1986; 13:69 –77 Vanderburgh L, Yeung EY, Ho CS. Radiologic management of problematic biliary calculi. Sem Intervent Radiol1986; 13:69 –77

32. 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. AJR1980

33. 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.

34. Adjuvant Techniques with ERCP +ES Laparoscopic CBD exploration/Choleydochoscopy. Laparoscopic CBD exploration/Choleydochoscopy. Mechanical lithotripsy Mechanical lithotripsy LASER lithotripsy LASER lithotripsy Electrohydraulic lithotripsy Electrohydraulic lithotripsy ESWL ESWL Chemical contact dissolution therapy Chemical contact dissolution therapy

35. 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.