2. INCIDENCE OF REPEAT ERCP COMPARED TO TOTAL

3. ERCP in England 1990-1999 90/91 98/99Increase % Diagnostic; Surgery502710400 Medicine616911252 Total1119621652 190 % Therapeutic; Surgery20378162 Medicine19808197 Total401716359 400 % All ERCP’s1521338011 250 %

4. ISD SCOTLAND 98/99 Cholecystectomy total 5126 Laparoscopic cholecystectomy 3827 Open or converted 25.3% 1299 ERCP 4792 SASM 1998, 164 ERCP deaths, 2.8 % 99 deaths in malignant dis., 99/949 (10.4 %) 65 deaths in benign conditions, 65/3000 (2.1 %) Therapeutic ERCP’s done in only 40 % !!

5. Neoptolemos J P,et al Br Med J. 1987;294:470-4 Prospective randomised study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones

6. Results do not support routine preop ES on the basis of efficacy, morbidity or cost ES/Surg Surgery Number 55 60 Stone clearance 91% 91.5% Major complications 16.4% 8.5% Minor complications 16.4% 13.6%

7. RISK FACTORS FOR CBD STONES ACUTE PAIN & RAISED LFT’s JAUNDICE & CBD DILATATION CBD DILAT.& RAISED LFT CBD DILAT. OR STONE ON USS CHOLANGITIS & JAUNDICE PANCREATITIS & RAISED LFT’s DILATED CD OR CBD AT LC CBD STONE ON PLAIN FILM

8. INDICATIONS FOR ERCP DIAGNOSTIC UNCERTAINTY, STONES LESS LIKELY ( IVC, PTC,MRC, EUS ) SEVERE ACUTE CHOLANGITIS UNRESOLVING PANCREATITIS HIGH RISK, ELDERLY, UNFIT FOR LC RETAINED STONES FAILED TCE, SMALL DUCT

9. INDICATIONS IN THE LAPAROSCOPIC ERA Clear the CBD before cholecystectomy ! Laproscopic IOC is time-consuming ! Plan operating lists ! No need for urgent biliary surgery ! Laparoscopic CBDE is difficult !

10. Lein-Ray M O et al, J Laparoendosc Surg.1993;3:10-22 The role of ERCP and therapeutic biliary endoscopy in LC Selection of 35 patients for preop ERCP, based on US and biochemical data Stones found in 16 (45.7%) >> ES

11. Berci G, J Laparoendosc Surg,1993:4:427 ‘.. More than half of the patients underwent,in my opinion, an unnecessary, risky and expensive examination’ ‘.. Surgeons performing LC should nowadays consider advancing their technique in learning how to do laparoscopic choledocho-lithotomy ‘.. I think it is the wrong philosophy to divide biliary stone disease to be treated in two sessions or even by two disciplines’

12. TWO-SESSIONS APPROACH, THE PROBLEMS PREOPERATIVE ERCP NEGATIVE IN UP TO 50% ERCP AND ES FAIL IN 10-35% ERCP MORBIDITY AND MORTALITY ES-LC INTERVAL COMPLICATIONS LONG TERM MORBIDITY OF ES THE COST

13. Wilson MS, Common bile duct diameter and complications of endoscopic sphincterotomy Br J Surg, 1992; 79:1346-7 Study of 655 patients In experienced hands, 30 day mortality of 0.5-1.5% and morbidity of 2.5-11.3% ES more hazardous in small papilla or if CBD is undilated or tapers distally Relative risk of complications increased 10 times if the CBD diameter was >8mm

14. Cetta F, CBD stones in the era of LC: changing treatments and new pathological entities. J Laparoendosc Surg 1994; 4:41-4 Need to preserve the Sphincter of Oddi SS & ES—9-11% stone recurrence within 6 years increasing with time. Recurrent brown stones due to stasis & infection High rate of long term complications of ES Resist ES without proper indication even at expense of risk of increased complications in the first phases of LCBDE

15. ALTERNATIVES REPEATING THE USS INTRAVENOUS CHOLANGIOGRAPHY CT SCAN; PANCREAS, CBD MRC ENDOSCOPIC ULTRASOUND OPERATIVE CHOLANGIOGRAM

16. CONSERVATIVE MANAGEMENT PANCREATITIS JAUNDICE / CHOLANGITIS JAUNDICE / ACUTE CHOLECYSTITIS ACUTE PAIN & RAISED LFTs

17. LOW-THRESHOLD SELECTIVE CHOLANGIOGRAPHY THE “ OBVIOUS” CASE ADMISSION WITH SEVERE PAIN DERANGEMENT OF “ANY” LFT RECENT JAUNDICE RECENT PANCREATITIS MULTIPLE SMALL STONES ON USS CD STONE/DILAT. OR DILATED CBD PREVIOUS ERCP – ES ; RECENT OR OLD

18. INDICATIONS FOR TCE SMALL STONES IN DISTAL CBD DILATED OR DILATABLE CD !! FACTORS TO CONSIDER : ANATOMY, NUMBER OF STONES, INSTRUMENTS

19. INDICATIONS FOR LCBDE LARGE, MULTIPLE OR PROXIMAL STONES FAILED TCE- CBD 8 mm + RETAINED STONES- FAILED ERCP

20. PREPARATION TRAINING STAFF IMAGING INSTRUMENTS CHOLEDOCHOSCOPE PATIENCE

21. ACCESS PORTS TYPE ; GRIP - VALVES PLACEMENT ; SITES - ANGLE - DISTANCE OPTIMAL USE ; SUTURING CHOLEDOCHOSCOPY

22. TRANSCYSTIC EXPLORATION INDICATIONS DILATING THE DUCT ?? IMAGE GUIDED EXPLORATION ; WHEN ? - PRECAUTIONS - PITFALLS CHOLEDOCHOSCOPE EXPLORATION DORMIA IN CHANNEL, PROBE ON CHD, LOW IRRIGATION STONE RETRIEVAL / TRANSFERE

23. TRANSCYSTIC EXPLORATION GLUCAGON BALLOON SPHINCTER DILATATION COMPLETION CHOLANGIOGRAM CYSTIC DUCT;TIE,CLIP, LOOP,DRAIN CAUSES OF FAILURE COMPLICATIONS

24. CHOLEDOCHOTOMY PREPARATION DISSECTING THE PEDICLE EXPOSING THE CBD SECURING THE CYSTIC DUCT ?CBDE - DEFINITE CBDE IOC ; CD - CBD IOC ; ANATOMY, SIZE OF CBD - NUMBER, SIZE, SITE OF STONES

25. CHOLEDOCHOTOMY TECHNIQUE EXPOSURE OPENING THE DUCT; POSITION, SIZE, TOOLS METHODS OF STONE RETRIEVAL; IRRIGATION, BALLOON, DORMIA, GRASPER CHOLEDOCHOSCOPIC CONTROL; CBD, INTRAHEPATIC DUCTS CHOLED/SCOPIC CHOLANGIOGRAM

26. CHOLEDOCHOTOMY DIFFICULT CASES MULTIPLE LARGE INTRAHEPATIC IMPACTED S- SHAPED DUCT

27. CHOLEDOCHOTOMY CLOSURE PRIMARY DRAINAGE; CD or T-TUBE COMPLETION CHOLANGIOGRAM ? CARE DURING GB DISSECTION SUBHEPATIC DRAIN SUCTION OF IRRIGATION FLUID SECURING THE T-TUBE

28. CBD EXPLORATIONS OPERATING TIME 1 H - 4 H 45M ( 2.20) MEAN HOSPITAL STAY 5.6 DAYS (ALL EPISODES) ADMISSION EPISODES 1.2 / PATIENT PRESENTATION TO RESOLUTION 20 D

29. Complications of ES are often more serious and directly related to the procedure Haemorrhage Duodenal perforations Pancreatitis Biliary sepsis

30. BERTHOU,ET AL. FRANCE JAN 97, EUR.J.COELIO SURG 200 CASES IN 6 YEARS AGE 22-93 MEAN 63 PREOP DIAGNOSIS 59 %, IOC 41% TCE 101, SUCCESS 68 ; 27 CBDE, 6 ERCP & ES CHOLEDOCHOTOMY 126, OK 122, 97% FAILED 4, OPEN 3, ES 1 MAJOR MORBIDITY 1% MINOR 8% RET STONES 3.5%, 1 STRICTURE 19/12

31. MARTIN ET AL, BRISBANE BR J SURG, 98, 85, 412 300 CASES IN 6 YEARS, ONE DEATH AGE 19-100 MEAN 56 OPERATION TIME 95 MIN ( 35-300) TCE 171 ( STENT IN 3 ) CBDE 129, 12 CONVERSIONS ( 4% ) POSTOP ERCP 21, STONES 9 (3% ) MAJOR MORBIDITY 7 %, REOP 3%

32. PAGANINI, LEZOCHE. ITALY SURG ENDOSC, 98, 12,23-29 161 CASES IN 5 YEARS. ONE DEATH 157 EXPLORATIONS;TCE 107,CBDE 50 CONVERSION 4 ( 2.4%), RETAINED STONES 8 (5%) MAJOR MORBIDITY 6 ( 3.8%) RECURRENT STONES 5 (3.2%)

33. CONSERVATIVE AND SURGICAL MANAGEMENT OF SUSPECTED CBD STONES SAVES 89% AN ERCP LAPAROSCOPIC MANAGEMENT - APPLIES TO ALL PATIENTS FIT FOR LC - AVOIDS ERCP COST, MORBIDITY& MORTALITY LOW RATES OF MORBIDITY, RETAINED STONES AND CONVERSION. TRAINING, SUBSPECIALISATION, COST AND CLINICAL GOVERNANCE IMPLICATIONS