年3月专题讲座CBDS的处理策略.ppt
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1、Common Bile Duct Stones- Management Options,解放军324医院肝胆外科 张丰深,Gallstones,Incidence 12% men and 24% women (from autopsy study in UK) 10-30% of gallstones will become symptomatic (1-2% per year) Incidence of CBD stones found before or during cholecystectomy 12%,Composition,Cholesterol (70-80%) Uncommon
2、ly pure cholesterol stones (10%) Most have calcium salts in their centre (90%) and 10% of these have enough calcium to be radioopaque Pigment (20-30%) BLACK-secondary stones associated with haemolysis or cirrhosis BROWN-primary stones associated with bile stasis or infection,Shojaiefard A, et al. Va
3、rious techniques for the surgical treatment of common bile duct stones: a Meta review. Gastroenterology Research and Practice, 2009; 1-12,Classification,Primary Stones (5%) Form de novo in CBD Related to biliary stasis and infection Tend to be brown pigment stones Secondary Stones (95%) Formed in ga
4、llbladder Tend to be cholesterol stones,Classification,Retained 2yrs post cholecystectomy,Presentation,Incidental findings at cholecystectomy Biliary colic Jaundice Pancreatitis Cholangitis,The 4 main liver enzymes 毛远丽, 刘志国, 孙志强, 等. 检验与临床诊断-肝病分册. 北京: 人民军医出版社, 2006:131-210,Risk stratification,Risk st
5、ratification,Initial classification of suspected choledocholithiasis according to Cotton criteria as determined by ERCP and MRCP (Calvo et al, Mayo Clin Proc, 2002),Risk Stratification,Predictive scores for each multivariate factor used to produce the scoring system (Menezes et al, BJS, 2002),Risk s
6、tratification,High risk if-CBD 6mm -2 or more abnormal LFTs -cholecystitis/pancreatitis ? Preoperative ERCP Intermediate risk-MRCP Low risk-USS then LC,Imaging,Plain x-ray Ultrasound CT MRCP ERCP,Ultrasound,Most widely used Easy to perform Causes little discomfort Avoid irradiation and contrast medi
7、a High reliability of diagnosing gallbladder stones (95%) Variable reliability of detecting CBD stones 23%-80% depends on body habitus and experience of sonographer,Endoscopic ultrasound,Studies using EUS to evaluate prior to ERCP Avoids cannulation of papilla and avoids the risk of cholangitis and
8、pancreatitis Sensitivity 93% Specificity 97% Approaches ERCP with experience,CT,Sensitivity for CBD stones causing obstructive jaundice 75% Stones usually isodense with bile (not useful for assessment of cholelithiasis) CT cholangiogram unsuitable in jaundice as contrast not excreted Important for i
9、maging of pancreas if suspicion of malignant disease and other abdominal organs,MRCP,Detail now approaches ERCP Technique relies on the principle of imaging fluid columns that are static, better images with dilated ducts and flow artifact can give false positive results Sensitivity 95% Specificity 8
10、9% Accuracy 92%,MRCP,Advantages No irradiation Avoids complications of ERCP in 5%-10% of patients Disadvantages Claustrophobic & noisy Contraindicated if metal implants/foreign bodies Diagnostic only-not therapeutic,ERCP,Considered gold standard for preoperative imaging CBD Both diagnostic and thera
11、peutic,ERCP、取石,Natural history (Tranter, Ann R Coll Surg Engl, 2003),Difficult to predict Prospective study, 1000 cases of symptomatic gallstones, 73% had features suggestive of CBD stones, but had no CBD stones at OT and considered to have passed the stone spontaneously Cases with cholangitis or ja
12、undice were less likely to pass spontaneously,Primary (common) bile duct stones,Usually due to ampullary stenosis, diverticula or impaired bile duct motility Often require choledochojejunostomy (subject to circumstances and patient age) Management with choledochotomy & T-tube drainage alone associat
13、ed with recurrence rates up to 41% Laparoscopic choledochoduodenostomy-an option for advanced laparoscopic surgeon, but concerns regarding long term consequences of bilioenteric reflux,Secondary bile duct stones,Found at the time of or within 2 years of cholecystectomy 12% cholecystectomies 90% have
14、 preoperative indications (jaundice, pancreatitis or abnormal LFTs) 5%-10% have no pre-op indication and are detected at IOC (filling defect, absence of filling terminal segment of CBD or delay/absence of flow into duodenum),The best management of CBD stones is still a matter of debate,ERCP,General
15、agreement ERCP is preferable in Post-cholecystectomy patients High risk surgical patients who still have a gallbladder Severe acute cholangitis Selected patients with acute biliary pancreatitis Failed transcystic exploration with a CBD 8mm,ERCP,Areas of disagreement First line management of CBD ston
16、es Preoperative CBD clearance,ERCP,CBD clearance 90%-95% with successful sphincterotomy (papillary dilatation is an alternative) Overall clearance 80%-95% (improves with experience of endoscopist) Major complications in 10%,ERCP complications,Acute (5%) Haemorrhage 1%-6% Acute pancreatitis 1%-19% Ch
17、olangitis Retroduodenal perforation 1%-2% Failure to clear or access duct 2%-18% Overall procedure mortality 1% 30 day mortality can reach 15% (reflects severity of underlying disease),ERCP complications,Medium Recurrent stones 2%-14% Cholangitis 1%-6% Bacterobilia 60% Late Bile duct malignancy 2% (
18、Prat et al, Gastroenterology, 1996 & Tanaka et al, Gastrointest Endosc, 1998),Difficult bile duct stones at ERCP,Stones 15mm Intrahepatic stones Multiple stones Impacted stones Stone proximal to biliary stricture Tortuous bile duct Disproportionate size of bile duct stone Duodenal diverticulum Bilro
19、th 2 reconstruction Surgical duodenotomy,Adjuvant techniques,Mechanical lithotripsy Extracorporeal shockwave lithotripsy Chemical dissolution Successful stone fragmentation has been reported in up to 80% of patients, but major drawback is the need for multiple treatment sessions and repeat ERCP to r
20、etrieve stone fragments,ERCP stent insertion,5% of cases where stone extraction fails either a nasobiliary tube or stent should be inserted for CBD decompression Stents may block after a few months, but bile often drains around stent If surgically unfit can change stents if jaundice recurs Recurrent
21、 episodes of cholangitis can lead to secondary biliary cirrhosis in the long term so careful consideration before surgery is totally discounted,Preoperative ERCP,Eliminates the intraoperative dilemma as to how to manage CBD stones Exposes a number of patients to an unnecessary procedure and associat
22、ed complications Successful cannulation of papilla 96.8% with stones cleared in 86%, 13% unnecessary ERCP with failure rate 4.5% and morbidity 2.2% (Hamy, Surg , Endosc, 2003) Randomised study has shown no significant advantage for patient treated with preoperative ERCP with sphincterotomy vs open c
23、holecystectomy and CBD exploration (Neoptolemos et al, Br J Surg, 1987),Preoperative ERCP,Cholecystectomy should routinely follow clearance of CBD except in those too frail for a general anaesthetic If the gallbladder is left intact it can be expected that 47% of patients will develop at least on re
24、current biliary event (Boerma et al, Lancet, 2002),Intraoperative ERCP,Described in literature but few centers consider it an appropriate use of resources,Postoperative ERCP,Dictated by local expertise and practice Small (5mm) stones found at IOC could be left to pass, follow up to 33 months found 2
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