Biliary stone diseases

Mathew Philip

PVS Memorial hospital

Kochi

Prevalence of gallstones by age and gender

Introduction

Eleven to 21% of cholelithiasis have concomitant CBDS at the time of surgery

Majority of CBDS form in GB and then migrate CBD

Pass into the duodenum following the bile flow

May remain in the choledochus owing to the smaller diameter at the Vater papilla

Clinical presentation

Asymptomatic Colicky pain Cholecystitis Biliary obstruction Ascending cholangitis Acute Biliary pancreatitis

CBD stones - Endotherapy

Diagnosis US,MRCP, EUS and ERC

Endoscopic retrograde cholangiography (ERC) changed the approach to CBDS

Role of EUS

Diagnosis of CBDS Comparable to MRC More sensitive for

Biliary microcalculi Small stone impaction at ampulla Biliary sludge

Reduce ERC interventions

Outline

Standard treatment of CBD stones

Define Difficult Bile duct stone

Factors associated with difficult CBD stones

Treatment strategies of difficult CBD stones

Outline

Standard treatment of CBD stones

Define Difficult Bile duct stone

Factors associated with difficult CBD stones

Treatment strategies of difficult CBD stones

Standard treatment of CBD stnes

Standard Treatment of CBD stones

Outline

Standard treatment of CBD stones

Define Difficult Bile duct stone

Factors associated with difficult CBD stones

Treatment strategies of difficult CBD stones

Difficult CBD Stone

Commonly refers to a stone > 15 mm in diameter Usually unable to make ES larger than 15 mm

Stones < 15 mm may be considered difficult if: Proximal to stricture Narrow intrapancreatic segment Impacted Multiple Intrahepatic Billroth II reconstruction ES length is limited – e.g., periampullary diverticulum

Outline

Standard treatment of CBD stones

Define Difficult Bile duct stone

Factors associated with difficult CBD stones

Treatment strategies of difficult CBD stones

The variables affecting the success of stone extraction

Stone size and shape Bile duct diameter Bile duct geometry Composition of the stone Bile duct strictures distal to the stone

Endoscopic technical difficulty of CBD Stones

Older age (>65 years) Previous gastrojejunostomy Larger CBD stone (≥ 15 mm) Impacted CBD stone Use of mechanical lithotripsy Short length of the distal CBD arm (<36mm) Acute distal CBD angulation (<135 degrees) Relative narrowing of distal CBD

GIE 2007; 66:1154-60

Reasons for unsuccessful CBD stone removal

Anatomic obstacles to cannulation Postoperative states Billroth II gastroenterostomy Roux-en-Y anastomosis Anastamotic strictures Ampullary or duodenal tumor mass Scared duodenum from prior PUD Periampullary diverticulum Ampullary edema or inflammation

Outline

Standard treatment of CBD stones

Define Difficult Bile duct stone

Factors associated with difficult CBD stones

Treatment strategies of difficult CBD stones

Principle for treatment Difficult biliary stone

Decrease stone size

Larger CBD orifice

Principle for treatment Difficult biliary stone

Decrease stone size

Larger CBD orifice

Endoscopic Management of Large Bile Duct Stones

Mechanical lithotripsy Intraductal shockwave lithotripsy

Electrohydraulic Laser

Extracorporeal shockwave lithotripsy Dissolution

MTBE Monooctanoin

Long term stents

Endoscopic Management of Large Bile Duct Stones

Mechanical lithotripsy Intraductal shockwave lithotripsy

Electrohydraulic Laser

Extracorporeal shockwave lithotripsy Dissolution

MTBE Monooctanoin

Long term stents

Mechanical lithotripsy

Integrated

Salvage

Mechanical Lithotripsy

Advantages Relatively easy to use Relatively low cost Prevents stone impaction Can be done at initial ERCP

Disadvantages Requires stone capture Very hard stones may not fragment Several baskets may be required for each patient

Soehendra Mechanical Lithotriptor

Mechanical lithotripsy- Salvage

Principle for treatment Difficult biliary stone

Decrease stone size

Larger CBD orifice

Large Balloon Dilatation of Sphincter

Bile Duct Stones

Failed Mechanical Lithotripsy

ESWL

Percutaneously Surgery

Cholangioscope- Laser- EHL Stent

Dissolve

Cholangioscope

Mother baby scope Two operators Fargile High repair costs No dedicated irrigation channel Limited two way steering

capability

Spyglass Single operator Four way steering capability Independent irrigation channel Diagnostic and therapeutic

capabiities

Mother-Baby Scope System

Spyglass

Spyglass

10 Fr catheter

Guidewire

Optical fiber

Direction dials + locks

Irrigation port

Cholangioscopy and Stone fragmentation

Endoscopic management of Calculous cholecystitis

Comorbidities Elderly Trans papillary GB stenting / drainage EUS guided cholecystoduodenostomy

Conclusions

Biliary lithiasis affects 10% to 20% of general population

CBDS in up to 20% Endoscopic removal successful in 80-90%

using standard techniques EUS has an important role and avoids

unnecessary ERC

Conclusions

Stone location, stone size, and bile duct features may render stones non extractable using standard retrieval techniques

Balloon sphincteroplasty helps in extracting bigger stone

Difficult stones mechanical lithotripsy is easiest and cheapest, if stone can be captured in basket

Conclusions

Using all endoscopic and ancillary techniques, stone clearance rate ~ 97%

Direct cholangioscopic stone removal could achieve near complete stone removal except in intra hepatic stones

CBDS management is multidisciplinary Tailored on available resources and

expertise