1. 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

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

3. 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

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

5. 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

6. * 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

7. 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):
EGHC APRIL 2012

8. 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 Jan-Mar;3(1):23-5
EGHC APRIL 2012

9. 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 Aug;59(8):
EGHC APRIL 2012

10. Pre op ERCP -Good
N 600 ,
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, 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 May; 85(3): 167–173.
EGHC APRIL 2012

11. 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):
EGHC APRIL 2012

12. ‘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

13. 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 Jun;176(6):527-33
EGHC APRIL 2012

14. 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/ 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 Nov;22(11):
EGHC APRIL 2012

15. 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 Apr-Jun;4(2):
EGHC APRIL 2012

16. 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 ?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 Jun;39(6):808-12
EGHC APRIL 2012

17. 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 Aug;130(8):880-5
EGHC APRIL 2012

18. "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 Nov-Dec;54(6):785-98
EGHC APRIL 2012

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

20. 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 < )
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 December; 244(6): 889–896
EGHC APRIL 2012

21. 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 Mar;18(3): (Sweden)
EGHC APRIL 2012

22. 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

23. 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: days
No pts w/ signs or symptoms of retained CBD stones during mean post-op follow-up of 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

24. 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):
EGHC APRIL 2012

25. 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:
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:
EGHC APRIL 2012

26. 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:
EGHC APRIL 2012

27. 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:
EGHC APRIL 2012

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

29. 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 August; 242(2): 188–192.
EGHC APRIL 2012

30. 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 (6%) had retained stones at OC.
OC was done for 590 (94%) of the 630 patients, and 45 (7.6%) –CBDS
POST Op-ERCP free of stones
Post Op ERCP Good option
Kullman E et all Eur J Surg.1996 Nov;162(11):873-80
EGHC APRIL 2012

31. 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 Feb;9(1):31-7
EGHC APRIL 2012

32. 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

33. 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:
Schroeppel TJ, Lambert PJ, Mathiason MA, Kothari SN. An economic analysis of hospital charges for choledocholithiasis
by different treatment strategies. Am Surg 2007; 73:
EGHC APRIL 2012

34. 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):
E GHC APRIL 2012

35. 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
EGHC APRIL 2012

36. 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

37. 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

38. If Post op ERCP Fails!!
EGHC APRIL 2012

39. 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

40. 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

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

42. 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

43. Thank you
EGHC APRIL 2012
EGHC APRIL 2012