Gallstone and Bile Duct Disease

The GI Perspective

Jon Walker, MD
Associate Professor – Clinical
Department of Internal Medicine
Division of Gastroenterology, Hepatology & Nutrition
The Ohio State University Wexner Medical Center

Cholelithiasis

1
 Cholelithiasis:
Gallstones
• Incidence
– 10% American adults
• Risk Factors
– Age
– Female
– Obesity y
– Estrogen/OCP/Pregnancy
– Hyperlipidemia
– DM
– Ileal disease/Resection

Cholelithiasis

• Sto
Stone e
– 75% cholesterol stones
– 25% pigment stones
• Black
• Brown
• Sludge

2
 Cholelithiasis
• Cholesterol Stones
– Normal Bile Components
• Cholesterol
• Phospholipids
• Bile salts
• Bilirubin
• Proteins
– Bile salts = keeps
p cholesterol soluble Wikipedia.org

• Micelles of above three components

– Low bile salts = stone formation
– High cholesterol concentration = stone
formation

3
 Cholesterol Stones
• Major problem: supersatured bile
(lithogenic)
– Mechanisms
• Increased biliary secretion of
cholesterol
• Increased hepatic synthesis of
cholesterol
• Decreased secretion of solubilizing
lipids & bile salts

Cholesterol Stones
• Decreased secretion of solubilizing bile
salts
• Decreased hepatic synthesis of bile
acids
• Bile salt malabsorption
• Biliary
y stasis
• Gallbladder dysfunction
• Impaired enterohepatic bile salt
circulation

4
 Cholithiasis:
Role of Enterohepatic
circulation

www.hcvets.com

Pigment Stones
• Increased bilirubin load presented to the liver
• Primarily unconjugated bilirubin
• Black Stones:
– associated with hemolysis
– Direct increase in unconjugated bilirubin
• Brown Stones
– associated with stagnant or infected bile
– Indirect via increase β-Glucuronidase

5
 Clinical Presentation
• 20% develop symptoms
• Biliary colic
– RUQ/Epigastric pain
– Last over an hour
– Occ radiates to right shoulder/back
• Dyspepsia
– Non-specific

Diagnostic Workup
• Abdominal xray
– 15% stones visualized
– Pigmented stones usually
radiopaque
• RUQ Ultrasound
– Examines liver and bile duct
– Calcified and non-calcified
stones
– Limited by small size
• Endoscopic ultrasound
– No size limitation
– Closer examination of bile
ducts
– Limited liver examination

Wikipedia.org

6
 Cholelithiasis

Stone Sludge & Stone

www.med-ed.virginia.edu

Treatment
• Surgery
– Only if symptomatic
symptomatic, unless
1. Calcified gallbladder
2. Sickle cell anemia
• Ursodiol not proven effective
• No medications proven effective
• Not clear if avoiding fatty foods reduces
symptoms

7
Choledocholithiasis

Choledocholithiasis
• Usually form in the GB and
migrate into the duct
• Exceptions
– Stasis in the duct
(stricture/stenosis)
– Increased bilirubin within
the bile (ie chronic
hemolytic anemia)

8
 Choledocholithias
• Symptoms
– Asymptomatic
– Cholangitis
• Fever
Charcot’s Reynold’s
• Jaundice
Triad Pentad
• Pain
• Hypotension
• Confusion
– Abnormal LFT
• Hyperbilirubinemia
• Elevated Alkaline Phosphatase
• +/- Transaminitis

Choledocholithiasis
• Laboratory Findings: Cholestatic Pattern
– WBC usually elevated
– Elevated bilirubin (primarily conjugated)
– Elevated alkaline phosphatase
– Elevated glutamyl transpeptidase (GGT)
– Normal to mildly elevated aspartate
aminotransferase (AST) and alanine
aminotransferase (ALT)

9
 Choledocholithiasis
• Imaging
– Primary diagnostic modality
– Ultrasonography
• Cutaneous
• Endoscopic ultrasound
– MRI/MRCP
– Endoscopic
p Retrograde
g Diagnostic
Cholangiopancreatogrophy (ERCP) &
– Percutaneous Cholangiogram Therapeutic
(PTC)

Choledocholithiasis
• Imaging
– Primary diagnostic modality
– CT
– Ultrasonography
• Cutaneous
• Endoscopic ultrasound
– MRI/MRCP
/ C
– Endoscopic Retrograde
– Cholangiopancreatogrophy (ERCP) Diagnostic
&
– Percutaneous Cholangiogram (PTC)
Therapeutic

10
 ERCP
• Side-viewing endoscope
passed through the
mouth into the second
portion of duodenum.
• Major papilla identified
and catheter inserted
with injection of contrast
• Flouroscopy utilized to
visualize the biliary tree
• Can evaluate for
stenosis, filling defects
(stones), bile leak

ERCP

Abnormal major papilla Sphincterotomy

11
Choledocholithiasis
ERCP

NORMAL CHOLEDOCHOLITHIASIS

Choledocholithiasis
ERCP – Basket Retrieval

www.daveproject.org

12
 Choledocholithiasis
Balloon extraction

www.daveproject.org

ERCP

Balloon Assisted Stone Extraction Post-Stone Extraction

13
 ERCP
• Highly sensitivity and specific for stones
– 90% sensitivity; 98% specificity
• Offers therapeutics in addition to diagnosis
• Complications
– Pancreatitis (2-10%)
– Perforation
– Bleeding
– Duct disruption

MRCP
• Magnetic Resonance
Cholangiopancreatography
• MRI visualization of the bile duct and
pancreatic duct
• T2 weighted imaging – water content
• High Sensitivity and Specificity for stones
• Visualization of abdominal anatomy:
pancreas, liver, etc.

14
Wikipedia.org

Wikipedia.org

15
 MRCP
• Romagnuolo et al Ann Int Med 2003
– Meta-analysis
– 92% sensitivity for stones
– 88% sensitivity for mass
• Drawbacks
– Decreased sensitivity for small stones with
normal duct size
– Unable to sample tissue
– Poor imaging of ampulla of vater
– Cloustrophobic patients
– Metal prostheses or implantable devices
– Contrast

Endoscopic Ultrasound
• Ultrasound probe at the end of an endoscope
• Maximum depth of penetration: 5-7cm
• Endoscopic
p ultrasound – minimal barrier between
probe and target (i.e. skin, muscle, fat, bowel,
peritoneal cavity)
– advantage over percutaneous U/S
– Improved resolutions
• Frequency adjustable
– Low frequency: greater depth of penetration, less
resolution
– High frequency: less depth of penetration, high
resolution
• Doppler available on both linear and radial
echoendoscopes
– Vascular assessment

16
Endoscopic Ultrasound
Camera Light

Needle Channel

Ultrasound Probe

Image not available

17
Normal Pancreas
Body/Tail

EUS

18
Normal CBD

Stone

19
Endoscopic Ultrasound
Fine Needle Aspiration

Pancreas Mass

20
 Endoscopic Ultrasound
• Garrow et al. 2007
– Meta-analysis
– Sensitivity: 89%; Specificity: 94%
• Tse et al. 2008
– Meta-analysis
– Sensitivity: 94%; Specificity: 95%
• Safe procedure
– Basic endoscopy risks
– Minimal risk of FNA
• High accuracy for mass identification and
malignant
li t diangosis
di i (w/
( / FNA andd cytology)
t l )
• Identification of microlithiasis
– Tandon 2001 Am J Gastro
– Use of EUS able to diagnose etiology in 21 of 31
idiopathic pancreatitis cases
– 16% with microlithiasis

EUS vs MRCP
• Both high positive and negative
predictive value
• Both diagnostic w/o therapeutic benefit
• Both safe procedure
• EUS better for detection/biopsy of small
tumors
• EUS better for evaluation for
microlithiasis
• EUS better for ampullary evaluation
(endoscopic and sonographic)

21
 Recommendations
Cholelithiasis Workup
• High suspicion
– Abnormal LFT
– Ductal dilation
– Acute gallstone pancreatitis
– ERCP
• Intermediate suspicion
– EUS
• Low suspicion
– MRCP

Summary
• Careful history and physical examination can be a
pivotal component in diagnosis of gallstone
disease
• While cholelithiasis is often easily diagnosed via
RUQ ultrasound,
lt d choledocholithiasis
h l d h lithi i can be b more
difficult
• The diagnostic workup and management of
choledocholithiasis depends highly on the level of
clinical suspicion
• EUS and MRCP are safe and accurate alternatives
to ERCP for diagnosis of choledocholithiasis.
• EUS offers added feature of identification and
biopsy of small malignant lesions of the distal bile
duct, pancreas head or ampulla that are often not
identified on MRCP or CT.
• ERCP should be used as initial modality only if
pretest probability is high.

22
 Gallstone and Bile Duct
Disease

Jeffrey W. Hazey, MD, F.A.C.S.

Associate Professor of Surgery
Center for Minimally Invasive Surgery
Division of General and Gastrointestinal Surgery
The Ohio State University Wexner Medical Center

Common Bile Duct Stones

The Problem

770,000 Cholecystectomies/year
77,000-
10-15% 115,000
CBDS

23
 Strategies
Common bil
C bile duct
d stones can be
b
managed/removed…
Pre-operatively
Intra-operatively
Post-operatively
p y
Procedurally (no operation at all)

Strategies - Endoscopic

• Selective Preop ERCP

– Cost-effective if > 80% probability
• Selective Post-op ERCP
• Intraoperative
t aope at e ERCPC

24
 Strategies - Operative

• Open common bile duct exploration

• LSCBDE
– Transcystic Duct (TCCBDE)
– LS Choledochotomy( LSCD)

Strategies - Other

Percutaneous transhepatic stenting and

removal +/- YAG laser fragmentation or EHL

Laparoscopic assisted transgastric ERCP in

post gastric bypass patients

25
 Open Common Bile Duct
Exploration
Technical considerations:
Transcholedochal
t-tube
Drainage

Common Bile Duct Stones

T-tube drainage

26
 Common Bile Duct Stones

T-tube drainage
g : Principles
p

1. Stenting of sphincter of oddi

2. Long t-tube tract

3. Elimination of downstream obstruction

Laparoscopic Common Bile Duct

Exploration
Technical considerations:
Transcystic
+/- balloon dilation cystic duct stump
simple closure of cystic duct

Transcholedochal
t-tube
L/S suturing techniques

27
Laparoscopic Common Bile Duct
Exploration
Technical considerations:

Experience in advance L/S techniques

Instrumentation: L/S choledochoscope and

supporting instruments

Time

Evaluation of Techniques

• Effectiveness

• Technical Complexity/Experience

• Cost

28
 CBDS: The Evidence

CBDS Randomized Trial

LSCBDE vs Postop ERCP
• Initial Clearance Rates 75%
• Final Duct Clearance 100% vs 93%
• Morbidity
– LSCBDE 7/40 ( 18%) { 3 bile leaks}
– Postop ERCP 6/40 ( 15%) { 1 bile leak}
• Hospital Stay
– LSCBDE 1 day ( 1-26)
– Postop ERCP 3.5 days(1-11)

29
 CBDS Randomized Trial
Criticism
• No prospective calculation of sample size
• Failure to evaluate quality of life and
economic impact
• ERCP results poor relative to reported
literature (95% success)
• Hospital
H it l stay
t could
ld depend
d d on timing
ti i off
ERCP
• Results of LSCBDE cannot be generalized

CBDS Survey
8,433 cases in Germany
• Morbidity 14%
• Mortality 0.6%
• Incidence of CDE
– 1991} 7.4%
– 1998}} 3.8%
• Surgeons prefer Postop ERCP (93%)
• LSCBDE does not play a role in Germany

Huttl,TP et al Zentralbl Chir 2002

30
 CBD Stones
Surgeon Experience
Ritchie et al,Ann Surg1999:230;533-543
Surg1999:230;533 543
- 2434 general surgeons
- # procedures on recertification
Application
- Mean # Cholecystectomies/
y Yr = 36
- Mean # CBDE/ Yr = 2
Conclusion: Surgeon experience unlikely
to support LSCBDE

LSCBDE vs Postop ERCP

A Decision Analysis

Urbach DR et al Surg Endosc 2001 15:4-13

Structure of the Decision Model
Assumptions
E ti ti off Probabilities
Estimation P b biliti

31
 LSCBDE vs Postop ERCP
A Decision Analysis
PATIENT WITH GALLSTONES
LS CHOLE AND IOC

SUCCESSFUL IOC UNSUCCESSFUL IOC

Type title here Type title here

CBDS NO CBDS LS CHOLE

TRANSCYSTIC CBDE LS CHOLE

SUCCESSFUL UNSUCESSFUL

COMP NO COMP LS CDE

SUCCESSFUL UNSUCCESSFUL

COMP VS NO COMP OPEN CBD POSTOP ERCP

SUCCESSFUL UNSUCCESSFUL SUCCESSFUL UNSUCCESSFUL

COMP VS NO COMP POST OP ERCP COMP VS NO COMP COMP VS NO COMP

COMP VS NO COMP

LSCBDE vs Postop ERCP

Assumed Probabilities LSCBDE

IOC Success 94%(80-100)

Sensitivity 89% (80-100)
Specificity 99% (80-100)
Transcystic Success 81%(60-100)
Bile Leak 1.3% (0-5)
LSCBDE Success 67% (40-100)
(40 100)
Bile Leak 2.6% (0-5)
Conversion to Open 56% (0-100)

32
 LSCBDE vs Postop ERCP
Assumed Probabilities ERCP
IOC Success 94% (80
(80-100)
100)
Sensitivity 89% (80-100)
Specificity 99%(80-100)
ERCP Success 98% ( 80-100)
p
Severe Complications 1.1% ( 0-5))
Sensitivity 90% (80-100)
Specificity 100% (80-100)
Stone Clearance 91% (80-100)

LSCDBE vs Postop ERCP

Base Case Cost Assumptions

Diagnostic ERCP $1441 (500-2000)

(500 2000)
Therapeutic ERCP $ 1971 (1000-3000)
IOC $ 368 ( 250-1000)
Transcystic CBDE $ 1094 (500-2000)
( y )
LSCBDE(“otomy”) $ 1769 ((1000-3000))
Open Chole(conversion) $ 1794 (1000-3000)
Complication Bile Leak $1178 (500-3000)
Complication ERCP $5478 (2000-20000)

33
 LSCBDE vs Postop ERCP
Incremental Cost vs LS Chole

LSCBDE $ 487.50

Postop ERCP $ 550.10

____________
LSCBDE ( $ 62.60 )
(Savings)/Cost

LSCBDE vs Postop ERCP

Cost-Effectiveness Ratio
LSCBDE $496.81

Postop ERCP $563.59

{ Routine Preop ERCP 1518.85}

34
 CBD Stones

Example: Minimally Invasive Surgery

35
Laparoscopic Common Bile Duct
Exploration vs. ERCP:
Cost Analysis

Pre-op ERCP > Intra or post-op

management of CBDS whether
open or L/S
Hazey, J.W., Rock, L.M., Marks, J.M., Asseff, D., Ponsky, J. Cost
Analysis of Endoscopic Retrograde Cholangiopancreatography in
Management of Suspected Choledocholithiasis.

Laparoscopic Common Bile Duct

Exploration vs. ERCP:
Cost Analysis

Laparoscopic management of CBDS

is the most cost effective

Hazey, J.W., Rock, L.M., Marks, J.M., Asseff, D., Ponsky, J. Cost
Analysis of Endoscopic Retrograde Cholangiopancreatography in
Management of Suspected Choledocholithiasis.

36
 Laparoscopic Common Bile Duct
Exploration vs. ERCP:
Cost Analysis

Intra-op or Post-op ERCP are the

most cost effective when skills
or instruments to perform L/S CBDE
are not available

Hazey, J.W., Rock, L.M., Marks, J.M., Asseff, D., Ponsky, J. Cost
Analysis of Endoscopic Retrograde Cholangiopancreatography in
Management of Suspected Choledocholithiasis.

Laparoscopic Common Bile Duct

Exploration
What is really done out there!

Pre-op ERCP w/ attempts to clear the CBD

Open or L/S CBDE with placement of t-tube if stones

remain at cholecystectomy (variable experience)

+/- Post-op ERCP

37
 Laparoscopic Common Bile Duct
Exploration
What you should do!
ERCP and
d clearance
l off duct
d t for
f “known”
“k ” CBDS
pre-operatively

Attempt to learn advanced laparoscopic techniques

in the event an unsuspected CBDS is found
at laparoscopic cholecystectomy

Duct clearance (open or L/S techniques) and/or

confirmation (IOC) at the time of surgery

Laparoscopic Common Bile Duct

Exploration
What you should do?

Little or no role to leave stones in place and

reliance on post-op ERCP for removal unless
experience dictates otherwise

38
 Complications …

Bile leak
Bil l k
Common bile duct injury
Retained stones
Infection/Abscess
Bleeding

SILS Cholecystectomy

39
 Complications Related Solely to
Cholecystectomy…

• Bile leak
– Common Bile duct, cystic, hepatic or
accessory ducts
• Bile duct injuries
– Complete transection, partial transection
j
• Bowel injuries
– Duodenum, colon, small bowel
• Vascular injuries
– Hepatic arteries, portal vein

Other Issues to Address Related

Solely to Cholecystectomy…

• Conversion to Open is NOT

considered a complication
• Intra-operative Cholangiography
• Undiagnosed pathology
– Cancer, liver disease

40
 Laparoscopic Cholecystectomy…

• Healthy 42 yo female
female, elective
laparoscopic cholecystectomy for
symptomatic cholelithiasis
• Re-admitted 3 days post-op with
pain
i andd bilirubin
bili bi off 4.3
43

Bile Duct Injury: Transection HIDA Scan

41
Bile Duct Injury: Transection CT Scan

Bile Duct Injury: Transection ERCP

42
Bile Duct Injury: Transection ERCP

Bile Duct Injury: Transection PTC

43
 Bile Duct Injury: Transection
Intra--Operative
Intra

Bile Duct Injury: Transection Intra-

Intra-
Operative Cholangiogram

44
 Bile Leak and/or Injury
Drain it…
Internal and External drainage
g

• Internal Drainage…
–ERCP, PTC
• External Drainage…
–Control of all bile collections

Bile Leak and/or Injury

Fix it…
Primary repair vs. reconstruction

• Primary repair with internal/external

drainage…
– T-tube, PTC
• Reconstruction…
– Roux-en-Y Hepaticojejunostomy*
Hepaticojejunostomy
– Choledochoduodenostomy

45
 Strategies - Other
Percutaneous transhepatic stenting and
removal +/- YAG laser fragmentation
or EHL

Laparoscopic assisted transgastric ERCP in

post gastric bypass patients

Percutaneous access and removal of CBDS

Percutaneous
P t transhepatic
t h ti choledochoscopic
h l d h i
holmium-YAG laser or EHL ablation of biliary
tract calculi is a viable alternative for stone
clearance in patients incapable of having their
stones removed endoscopically and unable or
unwilling to undergo surgery.
surgery

46
 Case:

73 yo female
female, s/p open cholecystectomy
with abdominal pain, increased lft’s and
ultrasound consistent with choledocholithiasis

Unwilling to undergo an additional operative

procedure

ERCP with ES

47
 PTC

Completion cholangiogram after

a single treatment

48
 Case:

62 yo male, s/p laparoscopic

cholecystectomy
h l t t
with abdominal pain, increased lft’s and
ultrasound consistent with
choledocholithiasis

Physiologically high risk to undergo an

additional operative procedure on
presentation

PTC

49
Percutaneous choledochoscopic view

Completion cholangiogram after

a single treatment

50
Laparoscopic assisted transgastric ERCP in
post gastric bypass patients

51