Biliary stricture with stones Mathew Philip PVS Institute of Digestive Diseases Kochi

Standard therapy for CBD stones ERC with sphincterotomy and stone extraction 85% to 90% of CBD stones can be removed with Dormia basket or balloon catheter

Difficult common bile duct stones Not amenable to extraction by the standard technique of sphincterotomy followed by use of a Dormia basket or balloon

CBD stone removal - Challenges Large stones (> 15 mm diameter) Impacted stones Intra hepatic stones Bile duct stricture Narrow distal CBD Poorly expandable common bile duct Difficult anatomy

Bile duct stricture with stones True strictures with stones

Bile duct stricture with stones Poorly expandable CBD with stones Chi-Liang Cheng et al WJG 2012

Management Endoscopic ESWL Surgery

Endoscopic techniques ERC/ ES / Mechanical Lithotripsy Balloon dilatation followed by lithotripsy Multiple Stents followed by lithotripsy later Cholangioscopy – Holmium laser lithotripsy/ EHL Permanent biliary stenting

Biliary stenting Potential definitive treatment in selected elderly patients who are poor candidates for surgery Endoprosthesis may reduce stone size May allow later clearance of unextractable stones Problems - cholangitis

ESWL Accepted modality for large CBD stones NBD and ESWL followed by stone removal and stenting Tandan M et al J Gastroenterol Hepatol. 2009

ESWL Pre ESWL Post ESWL Tandan M et al J Gastroenterol Hepatol. 2009

Surgery Lap vs. open Definitive treatment for stricture When ERCP is impossible or stone retrieval is incomplete, LECBD is the solution to difficult CBD stones

CBD stricture with stones Factors influencing treatment Associated cholangitis High risk patients Anatomical abnormality GB in situ with stones Intra hepatic stones(RPC)

CBD stones with strictures Cholangitis Young /stable /GB in situ Elderly /high risk patients ERC /NBD /Stent Surgery ERC /ESWL/Lithotripsy/Stent Surgery ERC /lithotripsy/Stent

Thank you