LCBDE, New target for the surgeon 4 IAIM

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The 27th Annual conference of Iranian Association of Internal Medicine, May 3 - 6, 2016 Razi center for conference Halls, Tehran, Iran.

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The 27th Annual conference of Iranian Association of Internal Medicine:

The 27th Annual conference of Iranian Association of Internal Medicine May 3 - 6, 2016 Razi center for conference Halls, Tehran, Iran.

Slide 2:

Consultant & Lecturer in Surgery, Department of General & Laparoscopic Surgery, Erfan Hospital, Tehran, Iran www.shahramnazari.com Shahram Nazari, M.D., SAGES Gastrointestinal Hybrid Endo-Laparoscopic Surgeon Laparoscopic Common Bile Duct Exploration New target, New opportunity بيست و هفت مين کنگره جامعه پزشکان متخصص داخلي

INTRODUCTION OBJECTIVES:

INTRODUCTION OBJECTIVES The last 30 years have seen major developments in the management of gallstone-related disease , which in the United States, alone, costs over 6 billion dollars per annum to treat. ERCP has become a widely available and routine procedure Open cholecystectomy has largely been replaced by a laparoscopic approach Laparoscopic Cholecystectomy may or may not include laparoscopic exploration of the common bile duct (LCBDE)

The importance?:

The importance? Common bile duct stones are found in approximately 10% in young, 25% in ages>65 ( overall 10%-16% ) of patients undergoing laparoscopic cholecystectomy. 25 % -50% of these cases become symptomatic if not treated . 4 - 8 % develop pancreatitis . There is not a screening test to detect CBD stones.

Methods of Diagnosis:

Methods of Diagnosis Pre-Op. Blood tests, Ultrasonography , CT Scan, MRCP , ERCP,EUS Intra-Op. Cholangiography , Sonography, Choledochoscopy Post-Op. Blood tests , Ultrasonography, CT Scan, MRCP , ERCP,EUS gallstones T hick S ludge

The problem?:

The problem? Clinical models are inaccurate (in some cases) in predicting CBD stones for all patients who will undergo cholecystectomy for gall bladder lithiasis . The probability that a patient have CBD stones is a key factor in determining treatment strategies. U/S (for CBD cal.) Sensitivity 15 % - 40 % MRCP Sensitivity 92 % Specificity 100 % CT scan Sensitivity 75 - 90 % Specificity 80 -100 % EUS Sensitivity 92 % Specificity 100 % MRCP : alerts the surgeon to the presence of stones in CBD and abnormal anatomy.

Pre-Op. founded CBD stones :

Pre-Op. founded CBD stones ERCP Open CBDE Laparoscopic CBDE

Intra-Op. founded CBD stones :

Intra-Op. founded CBD stones Post operative ERCP CBDE ( Open / Laparoscopic)

Post-Op. founded CBD stones :

Post-Op. founded CBD stones ERCP Re-operation CBDE ( Open / Laparoscopic)

ERCP indications:

ERCP indications Stent placement Strictures (benign or malignant) Fistulae Post-op bile leak High risk pts with large, unremovable CBD stones Balloon dilatation of ductal strictures Biliary or pancreatic Pancreatic pseudocyst drainage Nasobiliary drain placement Cholangitis Post-op bile leak Tissue sampling from biliary or pancreatic ducts Therapy of disorders of the PD

ERCP indications:

ERCP indications Sphincterotomy (ES) Choledocholithiasis To facilitate placement of biliary stent or balloon dilatation of biliary stricture Sphincter of Oddi dysfunction Sump Syndrome Choledochocele involving the major papilla Ampullary carcinoma (non-surgical candidates) Facilitate access to the pancreatic duct

ERCP Contraindications:

ERCP Contraindications Evaluation of abdominal pain of obscure origin in the absence of objective findings which suggest biliary or pancreatic disease Evaluation of suspected gallbladder disease without evidence of bile duct disease As further evaluation of proven pancreatic malignancy unless management will be altered

ERCP Contraindications to Sphincterotomy:

ERCP Contraindications to Sphincterotomy Coagulopathy Highest risk of post- sphincterotomy bleeding: Coagulopathy Anticoagulation within 3 days (after) Precut sphincterotomy Cholangitis prior to ERCP Bleeding during the ES Lower ERCP case volume

ERCP:

ERCP Pre-op ERCP has it`s problems: - failure 11-14% - Morbidity 5-10% - Mortality 0.02-0.5% - Pancreatitis 5%

ERCP:

ERCP Post op ERCP has same problems: - failure 11-14% - Morbidity 5-10% - Mortality 0.02-0.5% - Pancreatitis 5%

Possible complications of ERCP:

Possible complications of ERCP Injury to the Bile duct & complications due to Loss of Oddi`s function Failure to remove all of the stones in CBD (11-14%) Reoperation Bleeding Perforation of the intestinal tract Pancreatitis Infection Fibrosis & Stricture - Recurrent pain - Recurrent collangitis - Recurrent stones Legal issues

Prior to the development of LC:

Prior to the development of LC The management of these patients included: Open CBD exploration at the time of cholecystectomy . * T-Tube * Choledochoduodenostomy

In the era of LC:

In the era of LC An obvious lack of expertise in Laparoscopic surgeries, An obvious lack of suitable instruments , * I f the diagnosis of choledocholithiasis was established during IOC, the surgeon was confronted with a therapeutic dilemma-that was: The choice between conversion to open surgery , Or postoperative ERCP (two-stage treatment).

In the era of LC:

In the era of LC Surgeons elected to detect and treat preoperatively CBD stones by endoscopic sphincterotomy (ES). They considered laparoscopic common bile duct exploration (LCBDE) as an unduly, complex, and demanding procedure. With increasing experience of laparoscopic surgeons, it seemed logical to develop a mini-invasive one-stage procedure using the laparoscopic approach.

In this current era:

In this current era Open Surgery , which is an invasive procedure requiring a longer period of hospitalization and recovery. Endoscopic Retrograde Cholangio-Pancreatography (ERCP), a second procedure that requires an endoscopic specialist (often not available in smaller hospitals), with a 10% complication risk that includes pancreatitis and a 1.0% mortality rate. Patients who develop post ERCP pancreatitis can expect extended hospital stays of 48-94 days. (Waknine, Yael. Gut , Dec. 2003 ) Laparoscopic Common Bile Duct Exploration (LCBDE) includes either (a) transcystic or (b) choledochotomy procedures and is a minimally invasive operation with the lowest associated morbidity & mortality. No second operation is required and the patient's diseased gall bladder is removed during the same procedure. LCBDE provides for quick recovery, a short hospital stay (may even be performed in the ambulatory surgery setting), and has virtually no risk of pancreatitis.

Routine IOC:

Routine IOC To Find the silent stones To clarify the exact anatomy I generally start the procedure by clipping a ureteral catheter in the cystic duct and performing a cholangiogram.

Laparoscopic Ultra Sound for CBD assessment:

Laparoscopic Ultra Soun d for CBD assessment Lap US is the STETHOSCOPIC instrument of the surgeon in the era of endoscopic surgery US visualizes structures below visible surface Lap US and Cholangiogram are complementary

LCBDE:

LCBDE We have two opportunities: Transcystic LCBDE Choledochotomy LCBDE

Transcystic LCBDE :

Transcystic LCBDE A very simple technique to master using the video choledochoscope Any surgeon that can perform a cholangiogram should be able to safely perform a trans-cystic LCBDE using MIG, 2.8 mm flexible choledochoscope and nitinol stone basket The choledochoscope is introduced into the largest lumen of the Multi-channel Instrument Guide (MIG) , the small lumens are plugged The MIG protects the choledochoscope as it is passed through port valves cystic duct with its spiral valves

Transcystic LCBDE :

Transcystic LCBDE Indications <9 stones Stones distal to cystic duct-CBD junction Stones diameter <6mm Stones <4mm Saline flush & 1mg IV glucagon 3-4 min later flush again with saline Repeat Fluoroscopy/ Cholangiography <3mm stones may pass

Transcystic LCBDE :

Transcystic LCBDE Contraindications Intra hepatic stones Stones above cystic duct-CBD junction Stones diameter >7mm

Choledochotomy LCBDE:

Choledochotomy LCBDE Anterior choledochotomy allows for removal of large stones Removal of multiple stones is much less problematic Proximal and distal bile ducts easily inspected Multiple Instrument Guide (MIG) allows for insertion of choledochoscope and basket , balloon catheter or lithotripter into CBD while irrigation is infusing into CBD

Choledochotomy LCBDE:

Choledochotomy LCBDE Allows the complete inspection of the biliary tree and reduces need for ionizing radiation Larger diameter instruments may be used C-tube or T-tube allows for drainage of biliary tree for prolonged periods, and is much better tolerated than the naso-biliary catheter and is preferred method of drainage in treatment of cholangitis

Choledochotomy LCBDE:

Choledochotomy LCBDE Primary repair of the choledochotomy is acceptable when there is complete clearance of stone, mild inflammation with no evidence of cholangitis, and confirmed patency of the Ampulla of Vater The Ampulla of Vater is not cut or damaged as with papillotomy Less risk of pancreatitis (than seen with ERCP and papillotomy) Requires laparoscopic suturing

Choledochotomy LCBDE :

Choledochotomy LCBDE Indications Failed ERCP Multiple stones > 9 Stones diameter > 6-8mm Intrahepatic Stones Cystic duct diameter<4mm Distal or Posterior Cystic duct entrance Surgeon familiar with Lap Suturing Skills Poor availability of ERCP Patient after Billroth II gastrectomy One stage management with Lap.chole

Complications of LCBDE procedures:

Complications of LCBDE procedures Potential Complications of Surgery: - Bile Leakage (may need STENT by ERCP or Drainage under US/CT) - Hemorrhage 2 cases 1case - Infection Post operative: - Retained stones (may need ERCP/ES) Nill - CBD strictures (often persisting over several years) ?

Benefits of LCBDE for ERCP:

Benefits of LCBDE for ERCP Post ERCP retained stones (failure) 3 cases Extraction of impacted stent / basket 1 case Placement of guide wire to facilitate ERCP cannulation Repair of perforations 1 case

:

Duration : 56 month [2006(Apr) – 2011(Jan)] Total number of cases: 690 The inclusion criterion was the presence of ultrasound proven gallstones. Pre-op. diag . 99 ERCP 70 ERCP failed 12 Not sent for ERCP 17 LCBDE 29=17+12 Per-op. diag . 39 — Trans-cystic 2 Total cases for LCBDE 68 Choledochotomy 66 Contd. Our Series

:

Total cases for LCBDE 68 C-tube 21 T-tube 10 No -tube 6 Choledochoduodenostomy was performed in 24 cases. The mean operative time was 90-130 minutes (mean 95), which is significantly greater than conventional LC (range 20-40 minutes, mean 30). Contd. Our Series

Our Series :

Our Series Results Retained cal. 3 (2.9 %) Conversion 3 (2.9 %) Leakage 2 Bleeding Nil Mortality Nil Hospital Stay 3 - 6 days

Conclusion:

Conclusion laparoscopic treatment one-stage surgery , costs less , requires shorter hospitalization , and resulted in significantly fewer complications . laparoscopic common bile duct exploration, when feasible, should be the gold standard for the management of choledocholithiasis. Both laparoscopic choledochotomy and cystic duct approach are feasible approaches to LCBDE. LCBDE superior to ERCP in terms of patient safety and cost. Laparoscopic choledochotomy is the preferred procedure for LCBDE in difficult cases such as those with multiple or larger stones, with stones in intrahepatic ducts, in the presence of cholangitis, or in the presence of a small, brittle, or avulsed cystic duct.

Choledochoscopy & Stone extraction using a Basket:

Choledochoscopy & Stone extraction using a Basket

Laparoscopic T-tube insertion:

Laparoscopic T-tube insertion

Laparoscopic Choledochoduodenostomy:

Laparoscopic Choledochoduodenostomy

Post ERCP impacted Stent:

Post ERCP impacted Stent

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