Role of ERCP in Gall Stones disease with CBD stones-surgeon’s view Subash C. Gautam FRCS (Eng,Edn,& Glasg)FACS, HON. FRCSG CONSULTANT SURGEON Fujairah Hospital Fujairah UAE EGHC APRIL 2012

Common Bile Duct Stones in Patients for LC Get them before during or after With ERCP EGHC APRIL 2012

History 1882 Langenbuch – Cholecystectomy 1889 Abbe – Choledochotomy 1890 Ludwig Courvoisier – CBD exploration 1932 Mirizzi – Intraop cholangiography 1941 McIver – Rigid choledochoscopy 1957 Wild – Endoscopic ultrasound 1968 McCune – ERCP 1986 Muhe – LAP cholecystectomy 1991 Wallner – MRCP EGHC APRIL 2012

Preoperative Suspicion Blood tests Transabdominal ultrasound ERCP Endoscopic ultrasound MRCP EGHC APRIL 2012

INCIDENCE OF CBD STONES Liver Function Tests LIVER FUNCTION TESTS INCIDENCE OF CBD STONES NORMAL 4% One Abnormal Value 20% Three Abnormal Values 50% Lezoche, E. Surg Endosc. 9(10), 1995 EGHC APRIL 2012

* 600,000 cholecystectomies annually in the U.S., 8%-20% have CBD stones, no consensus on optimal management. ** “No single clinical indicator is completely accurate in predicting CBD stones prior to cholecystectomy.” * Liu, TH et al. Ann Surg 234(1), July, 2001. **Abboud, et al. Gastrointestinal Endoscopy, 44(4), October 1996 EGHC APRIL 2012

NIH Consensus Manage CBD Stones –Pre Operative , Per operative or Post Operative Consensus Development Panel. Gallstones and laparoscopic cholecystectomy. (National Institutes of Health Consensus Development Panel on Gallstone and Laparoscopic Cholecystetomy). JAMA 1993;269(8):1018-24. EGHC APRIL 2012

ERCP -First N 700, 78,(11.1%) Pre Op ERCP N 42,(6%) OC –failed ERCP,??? N 1 , missed stone –Post Op ERCP selective preoperative ERCP, and not routine peroperative cholangiogram-cost effective Investigation of bile ducts before laparoscopic cholecystectomy, Thumbe VK et all JSLS. 1999 Jan-Mar;3(1):23-5 EGHC APRIL 2012

Suspected stones Pre op ERCP Low morbidity 4/59 (6.8%) The management of common bile duct stones in patients undergoing laparoscopic cholecystectomy. 401 PATEINTS FOR LC Suspected stones Pre op ERCP Low morbidity 4/59 (6.8%) Failure to clear CBD 2 patients Pre op ERCP should be recommended Francechi D et all Am Surg 1993 Aug;59(8):525-32. EGHC APRIL 2012

Pre op ERCP -Good N 600 ,1993-1998 107 (18%) pre-operative ERC; of these, 41 patients (38%) CBDS Postoperative ERC -30 patients (5%) -seven (23.3%) CBDS Three patients (0.5%) had stones removed within 15 days of operation and four (0.7%) between 2.6 months and 1.8 years. Median follow-up was 5.0 years (range, 2.5-7.5 years) 48 cases - Stones were successfully extracted at ERC in 43 patients (89.6%) CONCLUSIONS: A policy of selective pre-operative ERCP is the most effective technique Selective cholangiography in 600 patients undergoing cholecystectomy with 5-year follow-up for residual bile duct stones. H. Charfare and S. Cheslyn-Curtis, Ann R Coll Surg Engl. 2003 May; 85(3): 167–173. EGHC APRIL 2012

ERCP Prospective randomized trial on pts w/ resolving gallstones pancreatitis 34 pts had Lap chole w/ Intra-op cholangiogram 29 pts had preop MRCP If MRCP negative ® Lap chole w/ IOC If MRCP positive ® ERCP followed by Lap chole MRCP prediction of CBD stones Sensitivity: 100% Specificity: 91% Positive predictive value: 50% Negative predictive value: 100% Accuracy: 92% Conclusion: Patients with resolving gallstones pancreatitis and a negative MRCP do not need pre-op ERCP or Intra-op cholangiogram Hallal AH, et al. MRCP accurately detects common bile duct stones in resolving gallstones pancreatitis. JACS 2005;200(6):869-875 EGHC APRIL 2012

‘Strict criteria’ For Pre Op ERCP In AC.Pancreatitis Pre op ERCP 135 ,CBDS n43 (32%) Mild gall stones pancreatitis n6 (17%) IOC N87 - CBDS 2% WITH STRICT CONTROL 3% MISSED! Role of ERCP for suspected Choledocholithiais in patients undergoing laproscopic Cholecystectomy Tham TC eat all Ann Surg 2003,Jan 45-49 EGHC APRIL 2012

Acute Pancreatitis and CBDS?? N 573, 45 pre op -7 post op ERCP N17 with IOC-8 CBDS IN PREOP ERCP-ONLY 21% WITH CBDS IN Ac.Pancreatitis IOC with ERCP or POST OP ERCP better?? The evaluation and management of known or suspected stones of the common bile duct in the era of minimal access surgery. Leitman ,IM et all, Surg Gynecol Obstet. 1993 Jun;176(6):527-33 EGHC APRIL 2012

109 without Stones on ERCP- 20 n with stones on OC during LC Incidence of residual choledocholithiasis detected by intraoperative cholangiography at the time of laparoscopic cholecystectomy in patients having undergone preoperative ERCP. Preoperative ERCP and interval LC with IOC from 5/96 to 12/05 -227 ERCP-118 CBD Stones 109 without Stones on ERCP- 20 n with stones on OC during LC Total p with 20 stones missed 12.9% ALL PATEINTS WHO HAD PREOPERATIVE ERCP SHOULD UNDER GO OC Pierce RA et all Surg Endosc. 2008 Nov;22(11):2365-72 EGHC APRIL 2012

The efficacy of preoperative endoscopic retrograde cholangiopancreatography in the detection and clearance of choledocholithiasis Common bile duct stones were detected endoscopically in 12 of 17 (71%) ERCP Pre Op –all cleared OC on LC 4 (30%) still had residual stones!!! All Pre Op ERCP to undergo OC on LC Taylor EW et all JSLS. 2000 Apr-Jun;4(2):109-16. EGHC APRIL 2012

202 childern LC between 1996 and 2002 -48 ?CBD Stones Management of suspected common bile duct stones in children: role of selective intraoperative cholangiogram and endoscopic retrograde cholangiopancreatography. 202 childern LC between 1996 and 2002 -48 ?CBD Stones (1) ERCP first: 14 of 48 patients (including 1 failed examination). 3-Posative 10 Negative (2) LC +/- IOC first: 34 of 48 patients. 28 Negative on OC 3 –Post Op ERCP for CBD Stones No adverse effects of a retained or passed stone No complications in those who had a concomitant sphincterotomy (12 of 20 ERCP patients, mean follow-up of 4.2 years Pre or Post Op ERCP –Does not matter Mah D et all J Pediatr Surg. 2004 Jun;39(6):808-12 EGHC APRIL 2012

Bile duct stones in the laparoscopic era Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary? laparoscopic transcystic duct exploration -safe & effective unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease Philips EH et all, Arch Surg 1995 Aug;130(8):880-5 EGHC APRIL 2012

"Sequential" treatment: is it the best alternative in cholecysto-choledochal lithiasis? 552 patients operated on for cholelithiasis from 1991 to 2001 62 (11.3%) underwent preoperative ERCP for suspected CBDS 40 patients (clearance: 97.5%) overall morbidity was 16% (10 cases of pancreatitis) Combined endoscopic-laparoscopic treatment seems to present more advantages Nardi M Jr. et all Chir Ital. 2002 Nov-Dec;54(6):785-98 EGHC APRIL 2012

PER OPERATIVE AND SURGICAL EXPLORATION Results for Preoperative Equivocal!! Is PER OPERATIVE BETTER!!! EGHC APRIL 2012

Preoperative Endoscopic Sphincterotomy Versus Laparoendoscopic Rendezvous in Patients With Gallbladder and Bile Duct Stones Group I patients (45 cases) –Pre Op ERCP Group II Per operative ERCP CBD clearance was 80% for Group I and 95.6% for Group II (P = 0.06). The morbidity rate was 8.8% in Group I and 6.5% in Group II Hospital stay was shorter in Group II than in Group I: 4.3 days versus 8.0 days (P < 0.0001) Preoperative ERCP with ES followed by LC v/s laparoendoscopic rendezvous technique allows a higher rate of CBD stones clearance, a shorter hospital stay, and a reduction in costs. Per oprative better Morino M, et all Ann Surg. 2006 December; 244(6): 889–896 EGHC APRIL 2012

Per operative ERCP Better January 2000 and December 2001, N 674 LC 592 of the patients, (87.8%) intraoperative cholangiography (IOC) In 34 (5.7%) IOC, IO-ERCP 100% cannulation 97.5% Clearance of CBDS CONCLUSIONS: The study suggests that elective IO-ERCP is a safe and efficient method for removing CBDS Intraoperative endoscopic retrograde cholangiopancreatography (ERCP) to remove common bile duct stones during routine laparoscopic cholecystectomy does not prolong hospitalization: a 2-year experience Enochsson L et all, Surg Endosc..2004 Mar;18(3):367-71. (Sweden) EGHC APRIL 2012

Surgical versus endoscopic treatment of bile duct stones Pre-operative ERCP versus laparoscopic surgical bile duct clearance-Morbidity NS,Cost slightly more in ES ,Hospital stay variable Post-operative ERCP versus laparoscopic surgical bile duct clearance –Clearance better with Surgery ,Morbidity NS SURGICAL CLERANCE BETTER Martin DJ, Vernon D, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database of Systematic Reviews 2006, Issue 2. EGHC APRIL 2012

Combined Laparoscopy and ERCP 45 pts underwent lap chole w/ intra-op cholangiogram 33 pts had successful intra-op ERCP with extraction of CBD stones No post-op complications Mean hospital stay: 2.55+0.89 days No pts w/ signs or symptoms of retained CBD stones during mean post-op follow-up of 9+4.07 months Ghazal AH, Sorour MA, El-Riwini M, El-Bahrawy H. Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique. Int J Surg 2009;7(4):338-46 EGHC APRIL 2012

First ERCP during LC was published in 1993, Intraoperative ERCP: What role does it have in the era of laparoscopic cholecystectomy? First ERCP during LC was published in 1993, Rendezvous technique for guide wire General Anesthesia Single stage Good for failed Pre operative ERCP Rabago LR eta all ,World J Gastrointest Endosc 2011 December 16; 3(12): 248-255 EGHC APRIL 2012

What are pros of Intraopertaive ERCP Selective technique so less pancreatitis Less Hospital stay and cost Alternative to LSBDSC Easier !! La Greca G et all Laparoendoscopic “Rendezvous” to treat cholecysto-choledocolithiasis: Effective, safe and simplifies the endoscopist’s work,World J Gastroenterol 2008; 14: 2844-2850 Morino M, Baracchi F, Miglietta C, Furlan N, Ragona R, Garbarini A. Preoperative endoscopic sphincterotomy versus laparoendoscopic rendezvous in patients with gallbladder and bile duct stones. Ann Surg 2006; 244: 889-893 EGHC APRIL 2012

Cons for Intraoperative ERCP Co-ordination of two Teams X-ray Machine in OT! Time La Greca G et all,Simultaneous laparoendoscopic rendezvous for the treatment of cholecystocholedocholithiasis. Surg Endosc 2009; 24:769-780 EGHC APRIL 2012

CURRENT ROLE OF INTEROPERATIVE ERCP Intraoperative ERCP perfect salvage- failed preoperative ERCP Patients requiring IOC for CBDS Lack of Expertise for Laparoscopic clearance Avoidance of open surgery Tzovaras G et all Laparoendoscopic rendezvous: an effective alternative to a failed preoperative ERCP in patients with cholecystocholedocholithiasis. Surg Endosc 2010; 24: 2603-2606 EGHC APRIL 2012

Has Post Operative ERCP Any place Pre operative equivocal Per operative has logistic problems! EGHC APRIL 2012

Postoperative ERCP Versus Laparoscopic Choledochotomy for Clearance of Selected Bile Duct Calculi From June 1998 to February 2003, 372 patients with BD stones had successful trans-cystic duct clearance of stones in 286 86 patients randomized into the trial operative time was 10.9 minutes longer in the choledochotomy group (158.8 minutes) hospital stay 6.4 days versus 7.7 days Bile leak occurred in 14.6% of those having choledochotomy with similar rates of pancreatitis (7.3% versus 8.8%) retained stones (2.4% versus 4.4%) reoperation (7.3% versus 6.6%) morbidity (17% versus 13%). Natheson L et all Ann Surg. 2005 August; 242(2): 188–192. EGHC APRIL 2012

47 (56%) CBDS - 3 (6%) had retained stones at OC. Management of bile duct stones in the era of laparoscopic cholecystectomy: appraisal of routine operative cholangiography and endoscopic treatment. 630 LC-84 PRE OP ERCP 47 (56%) CBDS - 3 (6%) had retained stones at OC. OC was done for 590 (94%) of the 630 patients, and 45 (7.6%) –CBDS POST Op-ERCP- 10 free of stones Post Op ERCP Good option Kullman E et all Eur J Surg.1996 Nov;162(11):873-80 EGHC APRIL 2012

Two groups Pre Op ERCP v/s Post Op ERCP Timing of endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy in the treatment of choledocholithiasis Two groups Pre Op ERCP v/s Post Op ERCP Preoperative ERCP group had two patients requiring two ERCPs for Clearance Postoperative ERCP group –No Failure False positive IOC was 6.7% , Negative preoperative ERCP 43%. Absence of cholangitis requiring emergent endoscopic decompression, suspected CBDS- LC First ERCP being reserved for patients with a positive IOC Eliminates many negative preoperative ERCPs. Ng T ,Amaral JF, J Laparoendosc Adv Surg Tech A. 1999 Feb;9(1):31-7 EGHC APRIL 2012

N 154 with Gall stone pancreatitis 30 Pre Op and 29 post op ERCP Pre Op V/s Post OP ERCP in mild to moderate gall stones Pancreatitis :prospective randomized trial N 154 with Gall stone pancreatitis 30 Pre Op and 29 post op ERCP OC on Post Op group In Pre op 30 ERCP v/s Post op 7 of 29 (24%) Hospital stay 11.7 v/s 9 days Without cholangitis Post op ERCP better Chang L et all , Ann Surg.2000 Jan 231 (1) :82-7 EGHC APRIL 2012

POST OPERATIVE ERCP AS TWO STAGE FOR CBDS Better for Endoscopist!! Indications outlines with OC Highly experienced Team Failure!!!-What next? Hospital Stay longer Rhodes M, Sussman L, Cohen L, Lewis MP. Randomised trial of laparoscopic exploration of common bile ductversus postoperative endoscopic retrograde cholangiography forcommon bile duct stones. Lancet 1998; 351: 159-161 Schroeppel TJ, Lambert PJ, Mathiason MA, Kothari SN. An economic analysis of hospital charges for choledocholithiasis by different treatment strategies. Am Surg 2007; 73: 472-477 EGHC APRIL 2012

Current Trends National Hospital Discharge Survey database 1979 to 2001: Frequency of ERCP vs CBDE Beginning of study: 47,000 CBDE’s per year End of study: 7,000 CBDE vs 43,000 ERCP Complication rates from CBDE 3.4% at beginning of study 17.4 at end of study “ERCP has replaced the need for most but not all CBDE” “Both choledocholithiasis treatment algorithms and clinical training paradigms need to account for the rarity of CBDE and high complication rates associated with it, by incorporation of training modules in surgical residencies and advocating referral to centers having expertise in biliary tract operations from surgeons with little CBDE experience” Livingstion EH, Rege RV. Technical Complications are Rising as Common Duct Exploration is Becoming Rare. JACS 2005;201(3):426-433 E GHC APRIL 2012

Early Management of Acute Gall stones Pancreatitis EDITORIAL No proven benefit of Early ERCP in absence of Cholangitis If severity getting worse-ERCP 48 hours for disobstruction of ampulla POST OP ERCP Good Option Vitale GC, Ann Surg. Vol 245,I,Jan 2007 18-19 EGHC APRIL 2012

Prospective study of CBDS in patients undergoing Lap.Chole. OC in all patients 997, n 46 (4.6%) –filling defect at LC –transcystic catheter left in situ At 48 Hours – 12 –normal OC , 26% false + At 6 weeks – 12 –normal OC 26% clearance At end of study –n 22 CBDS -2.2% of total ERCP on residual stones only!! Chollins C. et all , Ann Surg 2004 Jan,239 (1) :28-33 EGHC APRIL 2012

Intra-operative Decision Making Convert to open? Laparoscopic transcystic common bile duct exploration? Laparoscopic cholechotomy? Defer to post-op management? Open or laparoscopic biliary bypass? Transduodenal papillotomy? Combined laparoscopy + ERCP? EGHC APRIL 2012

If Post op ERCP Fails!! EGHC APRIL 2012

Liu TH et al: Patient evaluation and management with selective use of magnetic resonance cholangiography and endoscopic retrograde cholangio pancreatography before laparoscopic cholecystectomy. Ann Surg 234: 33-40, 2001 EGHC APRIL 2012

EAES 1998 Stones can be extracted during ERCP, or either before or (in exceptional cases) after LC Bile duct clearance should always be combined with cholecystectomy. Evidence for further special aspects of CBDS treatment is equivocal and drawn from nonrandomized trials only. Conclusions: The management of common bile duct stones is currently undergoing some major changes. Many diagnostic and therapeutic strategies need further study. EGHC APRIL 2012

What to do? MRCP ERCP-WHEN Lap Chole LUS Lap CBD Lap Cholangiogram Transcystic CBD EGHC APRIL 2012

Take home All Modalities have value Timing and procedure depends upon of Patient, place, expertise Pre Op , Per operative and post operative evaluations are paramount EGHC APRIL 2012

Thank you EGHC APRIL 2012 EGHC APRIL 2012