CBD stone management and its complication during management

1. Management of common bile
duct stone and its complications
Presenter:
Dr Lilamani Rajthala
MS Resident
General Surgery

2. Relevant Anatomy

3. Introduction: Choledocholithiasis
• Found in 6 to 12 % of patients with cholelithiasis.
• Increases with age.
• Above age of 60, incidence is 20-25% of patient with symptomatic gall stones.
Primary stones:
• Form in bile duct, usually brown pigment type.
• Associated with biliary stasis and infection due to biliary stricture, papillary
stenosis , tumor, or other stones.
• Usually <1 cm, Brownish yellow, soft and mushy.
• Secondary to bacterial infection caused by bile stasis.
• E coli secrete β-glucuronidase cleaves bilirubin glucuronide to unconjugated
bilirubin.
• Precipitates with calcium with dead bacterial cells and form soft stone in bile
ducts.

4. Introduction: Choledocholithiasis
Secondary stone:
• Vast majority form in gall bladder and migrate down to CBD.
• Usually cholesterol stones, variable amount of bile pigment and
calcium, always >70% cholesterol.
• Usually multiple, variable size, hard, faceted, irregular, mulberry
shaped or soft.
• Mostly radiolucent, <10% radiopaque.
• Supersaturation of bile with cholesterol, almost always due to
hypersecretion.

5. Clinical manifestation
• Silent and often discovered incidentally.
• Epigastric or right upper quadrant pain.
• Intermittent pain and transient jaundice: Temporarily impaction at
ampulla.
• Severe progressive jaundice.
• Complete or incomplete obstruction leading to cholangitis or
gallstone pancreatitis.

6. Investigation
Blood investigation:
• Liver function test: Elevated serum bilirubin, alkaline phosphatase and
transaminase.
• Normal in one third cases: do not preclude further investigation if
clinical suspicion is high.
• Complete blood count: Neutrophilia if cholangitis.
• Deranged coagulation profile: Obstructive jaundice or liver
parenchymal disease.

7. Investigation
Ultrasonography:
• Visualization of stone in CBD as well as documentation of GB stone if
present.
• Stone in distal CBD: bowel gas can preclude their demonstration.
• Dilated CBD> 8mm.
• Sensitivity and Specificity: 73% and
91% respectively.

8. Investigation
MRCP:
• Excellent anatomical details of biliary tree.
• CBD stone will appear as well defined dark filling
defects within CBD.
• Sensitivity and Specificity of 95% and 89% respectively in
detecting stones >5mm.
[Earl Williams et al, Updated guideline on the management of common bile duct stones, Gut 2017]

9. Investigation
EUS:
• Positioned in duodenal bulb.
• Uses high frequency sound waves to image the bile duct.
• CBD appears hyperechoic foci with characteristic acoustic shadowing.
• Frequency of 7.5 and 12 Mhz.
• Sensitivity of 94% and specificity of 95%.
• Sensitivity and specificity independent of the size of deposits.
• However depends on experience of performing surgeon.
• Suggests replacement of diagnostic ERCP with EUS due to possible complication.
[Jasoslaw Leszczyszyn, J Ultrason. 2014 Jun.]

10. Investigation
ERCP:
• Most studies concluded that routine ERCP not indicated.
• Safe, highly accurate and therapeutic potential.
• Study bile duct anatomy, identify abnormalities of bile
duct, rule out other differentials (eg. Malignancy)
Indications:
• Elevated LFT.
• Dilated CBD >8mm.
• CBD stone in USG examination.
• Coexisting pancreatitis.
• History of acute pancreatitis and jaundice.
[Laszlo Lakatos et al, World Journal of Gastroenterology. 2004 Dec]

11. Investigation
Contraindication:
• Absolute: medical condition precluding sedation and general
anesthesia.
• Relative:
• Anatomical condition that would impede endoscope access.
• Clinically significant coagulopathy

12. Investigation
CT scan:
• Routinely not used for the purpose of detecting CBD stone.
• Important role in identification of malignant obstruction.
• CT cholangiography with excreted biliary contrast can achieve
sensitivity(69-87%) and specificity ( 68-96%) for detecting CBD stone.
• Accuracy decreases with decrease in size of calculi and similar density
to bile.
[Earl Williams et al, Updated guideline on the management of common bile duct stones, Gut 2017]

15. Questions and Answers?

16. Management
• Endoscopic Management.
• Laparoscopic CBD Exploration.
• Open CBD Exploration.
• Percutaneous radiological stone extraction.
• Stenting alone.
• Dissolution Therapy.

17. Endoscopic management
• Minimally invasive technique and effective treatment.
• ERCP: Gold standard for diagnosis CBD stone.
• Advantage of therapeutic option.
• Diagnostic cholangiography in >90% cases with <5% morbidity
(cholangitis and pancreatitis)
• Recommended that patient diagnosed with CBD stone are offered
stone extraction if possible.

18. Endoscopic management
• Overall follow up to 4 years, 25.3% of patients developed unfavorable
outcomes: Pancreatitis, cholangitis, obstruction of bile duct.
• Endoscopic sphincterotomy with stone extraction.
• Does not eliminate the risk of recurrent biliary stone disease.
• 50% have recurrent symptoms if not treated with cholecystectomy.
• Failure: large stones, intrahepatic stones, multiple stones, altered
gastric and duodenal anatomy, impacted stones and duodenal
diverticula.

20. Endoscopic papillary balloon dilatation
• Adjuvant to biliary sphincterotomy, facilitate removal of large CBD
stone.
• EPBD alone increases the risk of PEP but considered in selected cases
with uncorrected coagulopathy or biliary access.
• 8 mm diameter balloon is recommended in EPBD alone.
• EPBD with sphincterotomy: Reduces need of mechanical lithotripsy.
• 10 mm balloon used- avoid dilatation beyond the diameter of bile
duct above.

22. Endoscopic balloon dilatation
Contraindication of EPBD without sphincterotomy:
• Biliary stricture or malignancy
• Previous biliary surgery
• Cholangitis
• Pancreatitis
• Prior access papillotomy
• Large CBD stone (>12mm)

23. Access papillotomy
• Adjunct to endoscopic biliary cannulation in cases where access is
difficult.
• Precut or needle knife papillotomy.
• Risk of pancreatitis and perforation.

24. Cholangioscopy:
• Allows endoscopic visualization within biliary tree and offer lithotripsy
under direct vision using electrohydraulic or laser energy.
• Earlier: “mother and baby” system- two operators.
• Newly, Single operator cholangioscope with fiber optic visualization
system passed through the duodenoscope.
• Electrohydraulic lithotripsy and laser lithotripsy results in high stone
clearance (73-97%).
• Cholangitis ( up to 9%)-prophylactic antibiotics.

26. Anesthesia supported ERCP
• Tolerability and success is higher if performed with propofol sedation
or general anesthesia.
• Propofol assisted ERCP: considered for complex cases like intrahepatic
ductal stones and cholangioscopy assisted lithotripsy.
• GA with Intubation: Morbid obesity, airway/ventilation problem.

27. Complication: Post ERCP pancreatitis
• Well recognized complication.
• Criteria:
• Clinical picture of pancreatitis, onset with 24 hour of procedure.
• Persistent amylasemia (over 24 hour) over 3 times the normal range,
• Hospitalization for at least 2 days.
• Frequency varies considerably with 2-5% most commonly reported.
• Emphasizes the necessity of reserving ERCP as therapeutic procedure.
[A lorgulescu, J Med Life. 2013 Mar 15]

28. Post ERCP pancreatitis
Pathophysiology:
• Mechanical injury of pancreatic sphincter or main pancreatic duct.
• Pancreatic sphincter edema due to sphincterotomy.
• Prolonged sphincter spasm.
• Excessive injection of contrast.
• Extrinsic compression of main pancreatic duct through distal CBD
stone.
• Bacterial contamination.

29. Post ERCP pancreatitis
Prevention:
• Prophylactic NSAIDs ( 100mg Indomethacin or diclofenac)
• Short term pancreatic duct stenting in high risk cases.
• In increased risk due to patient factors (young age , female, suspected
sphincter of Oddi dysfunction) or procedure relation (repeated
pancreatic duct cannulation)
• Insertion of 5 F pancreatic stent, optimum duration hours to days.
• Confirm spontaneous migration via abdominal X ray.
• When spontaneous migration doesn’t occur: Endoscopic removal.

30. Coagulopathy prior to Sphincterotomy.
• Patients should have CBS and PT/INR performed.
• Abnormal clotting due to biliary obstruction and liver parenchymal
disease.
• May cause GI Hemorrhage.
• For endoscopic stenting alone, warfarin in continued and other oral
anticoagulants omitted on morning of procedure.
• For sphincterotomy, discontinuation of oral anticoagulation 2-5 days
prior intervention.
• Bridging therapy is reserved for high risk cases.

31. Laparoscopic CBD exploration:
• Intra operative cholangiography to identify choledocholithiasis.
• At the time of cholecystectomy.
• Approach: Transcystic or choledochotomy.
Transcystic approach:
• Cystic duct dilated using Seldinger technique.
• Flexible choledochoscope is passed and advanced to CBD.
• Wire basket is passed to ensnare the stone and withdrawn.
• Contraindication: stones in common hepatic duct, small friable cystic duct,
multiple ( >8 )stones in CBD, large stone (>1 cm).

34. Laparoscopic CBD exploration:
Choledochotomy:
• Longitudinal incision on CBD.
• Incision size at least as large as largest stone.
• Choledochoscope inserted to distal duct and stone extracted.
• T tube placed an bile duct closed.
• Completion cholangiography.
• Contraindication: Small caliber bile duct (<6mm).

35. Laparoscopic CBD exploration:
• Success rate: 75% to 95%.
• Duct clearance up to 100% with the availability of intraductal piezoelectric
or Laser lithotripsy.
Complications:
• Predominantly related to choledochotomy ( bile duct leakage) and T tube
use (bile leakage, tube displacement).
• T tube inserted to avoid risk of bile leakage.
• But increased morbidity: discomfort for 10-14 days, inadvertent early
removal resulting leakage, peritonitis and reoperation, need of
postoperative T tube cholangiogram.

36. T tube drainage
• After CBD exploration with supraduodenal choledochotomy.
• Short transverse part (20cm) and long longitudinal part (60cm)
• Clinical use significantly decreased due to less invasive alternative.
Indication:
• To drain CBD after choledochotomy.
• Repairing limited injury of CBD over T tube.
• CBD drainage when ERCP and PTC fail to clear CBD obstruction.

37. Intraoperative cholangiogram
• Intraoperative cholangiography done selectively during
cholecystectomy
Indication:
• Any suspicion of cholelithiasis
• Pain at the time of operation
• Abnormal LFT
• Anomalous or confusing biliary anatomy
• Inability to perform postoperative ERCP like Roux-en-Y gastric bypass.
• Dilated biliary tree

38. Questions and Answers?

39. Open CBD exploration:
• Frequency has decreased.
• Carries low morbidity (8-15%) and mortality (1-2%).
• Indication: when concomitant biliary drainage is required.
• Midline or right upper quadrant incision.
• Kocher maneuver to expose distal CBD.
• Gentle palpation to assess offending stone, may be milked backward.
• Choledochotomy at supra duodenal bile duct.

40. Open CBD exploration:
• Flushing with a soft rubber catheter.
• Balloon catheter with wire basket under fluoroscopic guidance.
• Flexible choledochoscopes.
• T tube placement and cholangiogram before closure.

41. Open CBD exploration:
Drainage procedure:
• Indications: dilated bile ducts, multiple distal impacted stones, a distal
duct stricture with stones, intrahepatic stones, or primary bile duct
stones.
• For dilated biliary tree: Choledochoenterostomy.
• Includes Choledochoduodenostomy or Roux-en-Y choledocho
jejunostomy.

42. Choledochoduodenostomy
Indication:
• Dilated CBD >15 mm.
• Multiple CBD stones
• Intrahepatic calculi.
• Primary CBD stone.
• Residual/ recurrent stones.
• Stone impacted in ampulla of Vater.
• Papillary stenosis.

44. • Sump syndrome: Bile duct distal to anastomosis does not drain well
and may collect debris predisposing to cholangitis or biliary
pancreatitis.
Roux-en-Y choledochojejunostomy:
• 60-cm limb of jejunum for drainage.
• No risk of Sump syndrome but prevents future endoscopic evaluation
of biliary tree.

47. Transduodenal sphincterotomy
• Indication: Several stones in a nondilated biliary tree or impacted stone at
ampulla that cannot be removed through choledochotomy.
Procedure:
• Kocher maneuver.
• Longitudinal duodenotomy on lateral wall.
• Identification of ampulla and incision at 11 o’clock.
• 5 o ’clock avoided-entry of pancreatic duct.
• Duodenal mucosa sewn to the bile duct mucosa.
• 1.5 cm sphincterotomy is adequate.
• Closure of longitudinal duodenotomy in transverse fashion.

48. Stenting as treatment of CBD stone
• As sole treatment in cases with limited life expectancy or prohibitive
surgical risk.
• Ensure adequate drainage if CBD stones cannot be retrieved.
• Over a mean follow-up period of 14 months, 36% cholangitis rate in
patients who had stents changed on demand with an associated
mortality of 8%.
• Patients who had stents changed electively at three monthly intervals
had an 8% cholangitis rate and 2% mortality.
• Short term use followed by further ERCP or surgery.

49. Stenting as treatment of CBD stone
• Covered self expanding metal stents (SEMS) can be considered
alternative to plastic stents to drain bile ducts.
• Uncertainties over how long the stents should be left in place and
cost benefit ratio.
• ESGE recommend a plastic stent should be removed or exchanged
within 3 – 6 months to avoid infectious complication.

50. Difficult ductal stone
• Diameter>1.5 cm, unusual shape ( barrel shaped), location
(intrahepatic or cystic duct), anatomical difficult ( narrow bile duct
distal to stone, sigmoid shaped CBD, stone impaction, shorter length
of distal CBD, acute distal CBD angulation <135 degree)
• Mechanical lithotripsy, EPBD with prior sphincterotomy and
cholangioscopy or extracorporeal shock wave lithotripsy fail to
remove stones.
• Percutaneous radiological stone extraction and open duct
exploration.

51. Percutaneous radiological stone extraction
• Achieved by either a transhepatic or transcholecystic biliary fistula.
• Balloon dilation of the biliary sphincter, which allows stones to be
pushed in an antegrade fashion into the duodenum.
• Larger calculi will require lithotripsy (either mechanical,
electrohydraulic or laser)

52. Extracorporeal Shock wave Lithotripsy
• High pressure electrohydraulic or electromagnetic energy.
• Delivered to the designated target point to fragment stone.
• Naso biliary drain to allow fluoroscopic identification and targeting
CBD stone.
• Adverse effect: Pain, local hematoma, cardiac arrythmias, biliary
obstruction, hemobilia and hematuria.
• Contraindication: Portal vein thrombosis and varices in umbilical
plexus.
• Uncommonly used and not a first line treatment.

53. Dissolution therapy.
• Ursodeoxycholic acid with or without turpentine preparation has
been suggested.
• But two RCTs have investigated and revealed no significant difference
in reducing the rate of stone recurrence.
• Hence UDCA or other agents are not recommended.

54. In Specific Clinical settings:
With or without gall bladder:
• Cholecystectomy is recommended in all patients with CBD stones.
• Minimally invasive nature of ERCP -primary form of treatment in post
cholecystectomy status.
Cholangitis:
• Urgent biliary decompression with endoscopic CBD stone extraction
and/or biliary stenting.
• If not possible: Percutaneous radiological drainage.

55. Acute biliary pancreatitis:
• With associated cholangitis or biliary obstruction: Biliary
sphincterotomy and endoscopic stone extraction within 72 hours of
presentation.
• Early laparoscopic cholecystectomy offered at same setting.

56. Recurrent CBD stones
Risk factors
• Multiple common bile duct stones, biliary dilatation> 13 mm
• Prior open cholecystectomy
• Prior gallstone lithotripsy
• Hepatolithiasis
• Biliary stasis due to periampullary diverticula, papillary stenosis,
biliary stricture or tumor and angulation of the common bile duct.

57. Recurrent CBD stones
Management:
• Repeat endoscopic intervention.
• Surgical options: Biliary Drainage:
I. Choledochoduodenostomy
II. Hepaticojejunostomy
III. Transduodenal sphinteroplasty

58. Altered gastric and duodenal anatomy
• Balloon assisted ERCP or Endoscopic ultrasound directed transgastric
ERCP- require advanced endoscopic expertise.
Billroth II gastrectomy:
• Side viewing duodenoscope facilitates cannulation and subsequent
therapy.
• Using sphincterotomes modified to alter the orientation of the cutting
wire or by using conventional sphincterotomes that rotates.
• Biliary sphincterotomy using a needle knife, with a straight plastic
stent as a guide.

59. • Roux-en-Y gastric bypass:

60. Take home message
• All patients with CBD stone is offered stone extraction.
• USG and LFT may be normal in case of CBD stones.
• MRCP and EUS are highly accurate test in identifying CBD stone.
• Tolerability and success is higher in ERCP with sedation or anesthesia.
• Laparoscopic duct exploration and ERCP with sphincterotomy,
mechanical lithotripsy or cholangioscopy are highly successful.
• When endoscopic cannulation is not possible, percutaneous or EUS
guided procedure can facilitate.
• Percutaneous radiological stone extraction and open duct exploration
are reserved for small number of cases.

61. References
• Earl Williams et al, Updated guideline on the management of
common bile duct stones, Gut 2017 .
• Gianpiero Manes et al, Endoscopic management of common bile duct
stones: European Society of Gastrointestinal Endoscopy (ESGE)
guideline, Endoscopy 2019.
• Sabiston Textbook of Surgery, The biological basis of modern surgical
practice, 20th Edition.
• Schwartz’s Principles of Surgery, Ninth Edition.