1. Management of Common Bile Duct stones Dr. Daniel TM Chung Department of Surgery, Pamela Youde Nethersole Eastern Hospital, HK East Cluster Joint Hospital Surgical Grand Round Sept., 2008

2. Background 10%-18% of patients undergoing cholecystectomy have CBD stones Before the advent of ERCP/laparoscopy, patients with choledocholithiasis required open surgical treatment Development of endoscopy and laparoscopy, choices become more

3. Nowadays… The optimal treatment of choledocholithiasis is still a controversial issue Stone size Number of stone Timing of discover of CBD stone Size of cystic duct / CBD Patient’s general condition Previous surgery Availability of expertise Facilities

4. Objective To discuss various techniques for CBD clearance

5. MRCP Intra-op ERCP +/- ES Lap. Cholecystectomy +/- IOC +/- open USG Suspicion of CBD stones Stone Clearance Post-op ERCP +/- ES ECBD (laparoscopic / open approach) Preoperative ERCP +/- ES ERCP (patient’s condition)

6. Preoperative Endoscopic Therapy Elderly / Debilitated patients Jaundiced / cholangitis / severe pancreatitis 75-84% of patient remains symptom free up to 70-month follow-up Vazquez-Inglesias JL et al. Surg Endosc 2004 Schreurs WH et al. Dis Surg 2004

7. Disadvantages Less patient compliance Two-session treatment Longer hospital stay Risk of ERCP Routine pre-op ERCP: Up to 61% of patients with suspected common duct stones undergo an unnecessary ERCP with its associated morbidity Nataly Y et al. ANZ J Surg 2002

8. Postoperative endoscopic therapy Definitive treatment of CBD stones when: Lap ECBD failed to clear the duct Retained stones are discovered postoperatively Incidence 2.5% Comorbidities make a prolonged operation risky CBD small and prone to post-op stricture Disadvantage: possibility of failure in cannulation of CBD / removal of CBD stones

9. ECBD (Open/Laparoscopic approach) Endoscopically difficult stones: Stones > 15mm Multiple stones Impacted stones Distorted anatomy Tortuous bile duct Duodenal diverticulum Billroth II reconstruction / surgical duodenotomy

10. Laparoscopic ECBD Potential benefit: minimally invasive, shorter hospital stay, less pain, better cosmetic result Significantly reduced hospital stay compared with pre-op ERCP/ES + LC 100% success rate in salvaging failed pre-op ERCP Transcystic technique vs. choledochotomy Cuschieri A et al. Surg Endoc 1999 Tai CK, Tang CN et al. Surg Endosc 2004

11. Transcystic technique Successful ductal clearance in 80–90% of patients Complication rate: 5-10% Mortality rate: 0-2% Duration of hospitalization: 1-2 days Main advantage: avoid choledochotomy Cuschieri A et al. Surg Endosc 1999 Rojas-Ortega S et al. J Gastrointest Surg 2003 Thompson MH et al. Br J Surg 2002

12. Transcystic technique Choledochotomy (+/- choledochoscopy) Few in number of stonesNumerous stones < 1 cm in sizeLarge stones Situated distal to cystic duct entry Stones in CHD

13. Laparoscopic Exploration of the Common Bile Duct: 10-year Experience of 174 Patients from a Single Centre 1995-2005 1144 ES / 22 open ECBD / 174 lap ECBD M:F = 71:103 Mean age: 63 (SD = 16) 156 choledochotomies / 18 transcystic duct exploration Tang and Li, HKMJ 2006; 12:191-6

14. Indications of LECBD Patients no. n=174 Young patient (<60 years) with concomitant gallstones and CBD stones 68 (39%) Previous failed ERCP59 (34%) Large (>2cm) or multiple CBD stones 40 (23%) RPC (for drainage choledochoenterostomy) 34 (20%)

15. Morbidity / MortalityPatients No. Overall Morbidity34 (19.5%) Bile leak / stent migration / collection15 (8.6%) Residual stones14 (8.0%) Wound infection / bleeding4 (2.3%) Bile duct injury4 (2.3%) Blocked stent2 (1.1%) Cholangitis2 (1.1%) Retained stone inside peritoneal cavity1 (0.6%) Duodenal injury1 (0.6%) Intra-abdominal collection1 (0.6%) Intestinal obstruction1 (0.6%) Mortality (secondary to bile leak and collection)1 (0.6%)

16. Cuschieri Sgourakis Pre-op ESLC+LCBDEP valuePre-op ESLC+LCBDEP value n=150N=150N=36N=42 Morbidity12.8%15.8%0.5413%17%<0.87 Mortality1.5%0.75%NS2% NS CBD clearance (% of operations) 84% 0.9686%84%NS Length of hospital stay (mean days) 96<0.057.490.07 Edward H. Philips et al. J Gastrointest Surg, 2008

17. NethansonRhodes LCBDE (choledo- chotomy) Post-op ESP value LCBDE (transcystic) Post-op ESP value n=43 n=40 Primary ductal clearance 100%74%0.2075% NA Final ductal clearance 100% NS100%93%NA Morbidity 17% (14.6% bile leak) 13%NS00NA Mortality00NS00NA Length of hospital stay (mean days) 6.47.70.5713.5NA

18. Intra-operative ERCP: Advantages Treatment in one session Avoids overestimation of patients selected for pre-op ERCP on the basis of imaging as well as biochemical and clinical criteria Possible to carry out main bile duct laparoscopic or open exploration during same procedure in case of failure Catheterization and positioning of papillotom facilitated by a rendezvous between guidewire inserted through cystic duct into duodenum and the papillotom itself

19. Rendezvous

20. Intra-operative ERCP: Disadvantage Increase in laparoscopic cholecystectomy surgery duration Logistic difficulties in the procedure organization May require multiple units (e.g. surgeons and endoscopists) Experts required Supine position for ERCP

21. Preoperative Endoscopic Sphincterotomy versus Laparoendoscopic Rendezvous in Patients with Gallbladder and Bile Duct Stones Prospective, randomized trial 91 elective patients with cholelithiasis and CBD stones Diagnosed at MRC Mario Morino et al. Annals of Surgery, 2006

22. Group IGroup II Pre-op ERCP +ES followed by LC LC +intraop ERCP +ES No. of patients (n)4546 CBD clearance80%95.6%P=0.06 Morbidity rate8.8%6.5%NS Mortality rate0% Hospital Stay (day)8.04.3P < 0.0001 Mean total cost (Euro) 38342829P < 0.05

23. Two-stage Treatment with Preoperative ERCP compared with Single-stage Treatment with Intraoperative ERCP for Patients with Symptomatic Cholelithiasis with Possible Choledocholithiasis Rabago LR et al. Endoscopy, 2006 Prospective randomized study Success rate: similar Frequency of residual CBD stones, conversion rate, surgical morbidity: no differences Intra-op ERCP group: less morbidity, a shorter hospital stay, reduced costs

24. Our Hospital’s experience: LC + intra-op ERCP June 2006 - September 2008 n=12 (M:F = 9:3) Mean Age = 61.4 (22 - 79) Indications: Cholangitis: 11 Biliary pancratitis: 1

25. Cannulation rate: 100% Stone clearance: 66% (8 cases) 2 need conversion to laparotomy + ECBD 2 need post-op ERCP Morbidity No major surgical complications 1 case of severe pneumonia Mortality: 0% Post-op hospital stay: mean 5.75 days (1 – 14 days)

26. Operation Timing Mean operation time: 134.18 minutes (61 – 215 minutes) Mean operation time (June 2006 – Feb 2008) 150.83 minutes (120 – 215 minutes) Mean operation time (Feb – Sept 2008) 114.2 minutes (61 – 210 minutes)

27. Intraoperative ERCP Reasons for improvement in surgical time: Improvement in facilities Better cooperations among surgeons / endoscopists, nurses and other theatre staffs Mastering of techniques

28. Surgical versus Endoscopic Treatment of Bile Duct Stones 3974 articles reviewed 13 trials randomised 1251 patients 8 trials (n=760) (ERCP vs open surgical clearance) 3 trials (n=425) (pre-op ERCP vs lap clearance) 2 trials (n=166) (post-op ERCP vs lap clearance) Martin DJ et al. Cochrane Database Syst Rev. 2006

29. A significantly increased number of total procedures per patient was seen in ERCP arms ERCP was less successful than open surgery in stone clearance; with a tendency towards higher mortality Lap CBD stone clearance was as effective as pre- or post-operative ERCP; no significant difference in morbidity and mortality Laparoscopic trials: shorter hospital stays in surgical arms Insufficient data reported for cost analysis Conclusions: … In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones…

30. Conclusion Controversial Depends on expertise available, instruments, personal experience, patient condition