A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

BY: Jonathan R. Malabanan, M.D.

Ospital ng Maynila Medical Center Department of Surgery

General Data: A.M.

35 –years- old Female Binondo, Manila

Chief Complaint: Yellowish discoloration of the eyes

HISTORY OF PRESENT ILLNESS

One month PTC= =RUQ pain, colicky, moderate to severe, radiating to R scapular area =no fever, no yellowish discoloration of skin and sclerae =no consult, no meds

HISTORY OF PRESENT ILLNESS

One week PTC =persistence of colicky right upper quadrant pain =yellowish discoloration of skin and sclerae =(+) light colored stool =(+) consult, HBT- UTZ done: Choledocholithiasis, Cholecystolithiais Advised OR, and was scheduled for operation

Past Medical History

• No hypertension • No diabetes • No PTB • No previous hospitalization • No allergies to foods and drugs

Family History

• unremarkable

Personal and Social History

• Unremarkable • Occasional alcoholic beverage drinker

Physical Examination

• General Survey: – Conscious, coherent, not in respiratory distress • Vital Signs BP = 110/ 60 mmHg CR = 81 bpm RR = 20 cpm Temp: 37 degrees Celsius

Physical Examination

• Skin: yellowish coloration of skin • HEENT: - Pink palpebral conjuctivae, icteric sclerae, no CLAD, no TPC, no NAD, supple neck.

• Chest: – Symmetrical chest expansion, no retractions, – CBS

Physical Examination

• Heart normal rate, regular rhythm, no murmur • Abdomen Flat, NABS, soft, with Direct Tenderness RUQ, no organomegaly .

Physical Examination

• Extremities: – Full and equal pulses, no deformities, no cyanosis DRE: -light colored stool

Salient Features

• 1. 35/Female • 2. RUQ pain • 3. Yellowish discoloration of the eyes, skin • 4. Light colored stool • 5. UTZ result of Hepatobiliary Tree: dilated CBD, normal liver, portal vein and tributaries are unremarkable, intrahepatic ducts not dilated, with an intraluminal echogenic focus exibiting acoustic shadowing

JAUNDICE NON OBSTRUCTIVE OBSTRUCTIVE HEMOLYSIS INTRAHEPATIC EXTRAHEPATIC INTRADUCTAL COMPRESSION OF BILIARY TRACTS HEPATOCELLULAR

OBSTRUCTIVE EXTRAHEPATIC GB/CBD stones Pattern Recognition (90-95%) RUQ pain Clinical Jaundice CBD dilatation Pancreatic Ca INTRAHEPATIC Primary Biliary Cirrhosis Sclerosing Cholangitis

Initial Impression

Diagnosis Primary Diagnosis

Obstructive Jaundice prob secondary to Choledocholithiasis Cholecystolithiasis

Secondary Diagnosis

Jaundice prob secondary to Chronic Liver Disease

Certainty

95% 5%

Para clinical Diagnostic Procedure • Do I need to perform a Para clinical diagnostic procedure?

“No”

Pretreatment Diagosis

Diagnosis Certainty Primary Diagno sis

Obstructive Jaundice prob secondary to Choledocholithiasis Cholecystolithiasis 95% SURGICAL Medical

Second ary Diagno sis

Jaundice prob secondary to Chronic Liver Disease 05% MEDICAL

Pre Treatment Diagnosis Obstructive Jaundice prob secondary to Choledocholithiasis Cholecystolithiasis

GOALS OF TREATMENT

A. Resolution of obstruction B. Prevention of complication

Treatment

ERCP Open surgery Laparo scopic surgery

Treatment Options

Benefit -able to achieve primary treatment objective SR=81-98% CBD Clearance -bleeding -perforation -pancreatitis Risk Cost *12-15,000 -able to achieve primary treatment objective SR=90-100% CBD Clearance -able to achieve primary treatment objective SR=85-100% CBD Clearance -complications of anesthesia -bleeding -iatrogenic injury to biliary ducts -complications of anesthesia -bleeding -iatrogenic injury to biliary ducts -trocar and needle insufflation injuries Availability Not available *20-30,000 pesos in private hospitals *free to charity pxs at OM *40-60,000 pesos in private hospitals available Not available Meta-analysis of

endoscopy and surgery

versus surgery alone

for common bile duct stones with the gallbladder in situ, Clayton et.al.

University of Athens 2006

Management

• •

OPEN CBDE CHOLECYSTECTOMY, IOC

Preoperative Preparation

• Informed consent • Provide psychosocial support • Optimize patient’s condition • NPO for 6 hours • Preparation of OR materials

Operative technique

• Patient supine under GA • Asepsis/Anti-sepsis • Sterile drapes placed • Right paramedian incision carried down from skin to subcutaneous tissue, fascia and peritoneum entered • Intraoperative findings noted

Operative Technique

• Cystic artery identified, ligated and cut • Cystic duct identified, isolated and tagged • Gallbladder removed. Intraoperative findings noted.

• French 5 feeding tube inserted into the cystic duct, IOC done, results noted • CBD opened logitudinally and explored

Operative Technique

• T-tube inserted and anchored • Hemostasis • Correct sponge and instruments count • Layer by layer closure • DSD

Operative Findings

• Intraoperative findings noted –

GB is distended with thickened walls measuring 10x4cm; on opening up, it contained multiple stone measuring 0.2-0.3cm, cystic duct measures 0.5cm in diameter; CBD measured 12mm in diameter; on IOC, there was a filling defect on the distal CBD, there was visualization of both intrahepatic ducts. On CBDE, 8mm primary stone was noted at the distal common bile duct. Pancreas was normal. Liver was noted to be cirrhotic.

Postoperative Diagnosis

Obstructive Jaundice Secondary to Choledocholithiasis Cholelithiasis Operation Done

Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy

Postoperative Management

• Adequate analgesia • Monitoring of VS and hydration.

• DAT • Adequate monitoring: complications • Patient was discharged on the 5th post operative day • Follow up after a week.

Final Diagnosis

• • Obstructive Jaundice Secondary to Choledocholithiasis • Cholelithiasis

S/P Open Cholecystectomy, Common Bile Duct Exploration, Intraoperative Cholangiography, T-Tube Choledochostomy

COURSE IN THE WARD

• 1 st Hospital Day – NPO – Adequate Antibiotic – Adequate Analgesia – DWC

COURSE IN THE WARD

• 2 nd -3 rd Hospital Day – GL- Soft diet – Adequate Antibiotic – Adequate Analgesia – DWC

COURSE IN THE WARD

• 4 th Hospital Day – DAT – Adequate Antibiotic – Adequate Analgesia – DWC

COURSE IN THE WARD

• 5th Hospital Day – Patient discharged

PREVENTION AND HEALTH PROMOTION

• Advise given to patient regarding – Possible complications – Proper wound care • OPD follow up after 7 days for removal of sutures • Anticipate complications – Avoid Recurrence – Avoid infection

SHARING OF INFORMATI0N

Common Bile Duct Stones

• 10% of patients who present for Cholecystectomy • definitive treatment is cholecystectomy and ductal clearance either through open CBDE, Lap CBDE, ERCP.

• Manuevers include administration of glucagon and flushing of ductal system,dilatation of the distal CBD, balloon catheter, basket extraction.

• •

Overview to Patient Management

CBD stones can be discovered preoperatively, intraop, post-op.

Treatment options: – ERCP=/-S – Lap CBDE – Lap Chole + ERCP – Open CBDE – almost same success rate

Completion CBDE

• T tube placement: – decompression of the duct, incase of residual obstruction – access for ductal imaging postop – access for removal of stone – left as early as 4 days up to 6 weeks – complicatios: bile leaks, peritonitis

– – Post Cholecystectomy CBDE Problems • • • Early Problems bile duct injury: laceration, cystic duct stump leak, liver bed leak bile duct obstruction: retained stone biliary pancreatitis • • • Late Problems stricture postcholecystectomy syndrome GERD

Questions

#1 (MCQ) Which of the following is the main chemical component of pigment stones?

A. Cholesterol B.

Calcium bilirubinate

C. Calcium carbonate D. Calcium phosphate E:

Calcium oxalate

Questions

#2 (MCQ) What is the most commonly isolated bacteria in the common duct of patient with primary stone?

A. Escherichia coli B. Pseudomonas aeruginosa C. Klebsiella sp.

D. Salmonella typhii E. Corynebacterium sp.

Questions

#3 (MCQ) Which of the following is the best indication for preoperative ERCP in patients with gallstones?

A. Gallstone pancreatitis B. Obstructive jaundice C. History of jaundice D. Increased alkaline phosphatase to twice normal E. 1.6 cm common bile duct dilatation

Questions

(MCR) Direction: Write “A” if 1, 2, and 3 are valid statements.

“B” if only 1 and 3 are valid statements.

“C” if only 2 and 4 are valid statements.

“D” if only 4 is a valid statement.

“E” if all are valid statements.

Questions

#4 (MCR) The following are drainage procedure after open/laparoscopic CBDE.

1. Sphincteroplasty 2. Choledochojeunostomy 3. Choledochoduodenostomy 4. Choledochotomy

Questions

#5 (MCR) Correct statement about biliary scintigraphy using technetium 99m- labeled derivatives of iminoacetic acid (HIDA) include:

Questions

#5 (MCR) 1. Nonvisualization of GB is strong evidence of cystic duct obstruction.

2. The isotope is cleared by Kupffer’s cells 3. The GB in a fasting subject is normally visualized within 60 minutes of the dye injection 4. The scan is the preferred initial step in identifying common duct stones

Journal Appraisal

• Evaluation of primary duct closure vs T tube drainage following choledochotomy

Marwah

Sanjay,

Singh

Ishwar,

Godara

Rajesh,

Sen

Jyotsana,

Marwah

Departments of Surgery, Postgraduate Institute of Medical Sciences, Rohtak, Haryana, India

Year

: 2004 | Nisha,

Karwasra

RK

Volume

: 23 |

Issue

: 6 |

Page

: 227-228

Objective

• To assess the benefits and harms of primary closure versus routine T-tube drainage in open common bile duct exploration for common bile duct stones.

Design:

• Randomized Control Trial

Patients:

• Forty consecutive patients undergoing elective minilap cholecystectomy and CBD exploration for gallstones with CBD stones (proved preoperatively on ultrasonography) were studied prospectively.

Intervention:

• Patients were randomly divided in two groups: Group A underwent primary closure of CBD, group B had T-tube drainage after CBD exploration.

Main outcome measures:

• The duration of hospital stay, mortalities, morbidities and outcome.

GRP A GRP B

Results:

DURATION OF SURGERY (p<0.001)

87.75 min.

116.65 min.

GRP A GRP B

Results:

DURATION OF ANALGESIA (p<0.001)

3.35 days 5.3 days

GRP A GRP B

Results:

DURATION OF ANALGESIA (p<0.001)

3.35 days 5.3 days

GRP A GRP B

Results:

Morbidity

5% 40%

GRP A GRP B

Results:

Mortality

0% 5%

GRP A GRP B

Results:

Length of Hospital Stay

4.4 days 15.4 days

Conclusion

• The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality.

Clinical Question

• In cases of obstructive jaundice secondary to choledocholithiasis, is mandatory t- tube choledochostomy necessary?

Tentative Answer

• No – mandatory t tube choledochosyomy is not necessary for cases of obstructive jaundice secondary to choledocholithiasis.

Appraisal Guide

Are the results of the study valid?

Primary Guides:

1. Was the assignment of patients to treatment randomized?

Yes.

Are the results of the study valid?

Primary Guides:

2. Were all patients who entered the trial properly accounted for and attributed at its conclusion?

Yes.

Are the results of the study valid?

Secondary Guides:

Were patients, their clinicians, and study personnel "blind" to treatment?

No.

Are the results of the study valid?

Secondary Guides:

5. Aside from the experimental intervention, were the groups treated equally?

Yes.

Are the results of the study valid?

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.

Are the results of the study valid?

Secondary Guides:

4. Were the groups similar at the start of the trial?

Yes.

Conclusion

• The use of T-tube following routine choledochotomy is unnecessary and increases postoperative morbidity and mortality. • Primary closure of CBD is more safe and physiological and the procedure of choice following routine choledochotomy.

References

• Schwartz et. al Principles of Surgery.8

th ed. Chapter 6.

• Marwah S, Singh I,Godara R, Sen J,MarwahN, Karwasra RK. Evaluation of primary duct closure vs T tube drainage following choledochotomy.

Indian Journal of Gastroenterology 2004;23(6):227

–8.

• Wright BE, Freeman ML, Cummings JK et. al.: Current Management of Common Bile Duct Stones. Surgery. 132:729-735, 2002.

EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON COMMON BILE DUCT STONES FOR SURGICAL PROCEDURES: UPDATE 2004

COMMON BILE DUCT STONES

• 1. What is the recommended ancillary procedure in a patient with suspected common duct stone to confirm its diagnosis?

Magnetic resonance cholangiography is the recommended procedure for patients with suspected common bile duct stones to confirm the diagnosis.

• 2. What is the recommended treatment for patients with CBD stones without cholangitis?

• The recommended treatment for patient with CBD stones without cholangitis is surgical treatment.

• 3. Among the different treatment options for common bile duct stones, which procedure has the least recurrence?

• Choledochoduodenostomy has the least recurrence.

• 4. What is the recommended treatment for patients with gall bladder stones after endoscopic common bile duct clearance?

• The recommended treatment for patients with gall bladder stones after endoscopic common bile duct clearance is surgery, to be performed within 24 to 48 hours after clearance.

INTRAHEPATIC STONES (HEPATOLITHIASIS)

• 1. What is the recommended diagnostic tool to confirm the presence of intrahepatic stones with or without strictures?

• Magnetic resonance cholangiography is the recommended diagnostic tool to confirm the presence of intrahepatic stones.

• 2. What is the recommended treatment for intrahepatic stones with or without strictures?

• The recommended treatment include surgical management (hepatic resection) and cholangioscopic techniques, whether through a T-tube tract, a percutaneous transhepatic approach (PTBD/PTCS) or a transpapillary approach, singly or in combination.

CHOLANGITIS

• 1. What is the antibiotic of choice for patients with cholangitis?

• The recommended antibiotics for the treatment of cholangitis are: Ciprofloxacin 200mgs IV BID or Ceftazidime 1gm IV BID + Ampicillin 500mgs IV QID + Metronidazole 500mgs IV TID

• 2. What is the recommended treatment for patients with severe cholangitis?

• The recommended treatment for patients with severe cholangitis is non-operative biliary drainage (endoscopic).

RETAINED COMMON BILE DUCT STONES

• 1. What is the recommended treatment for retained common bile duct stones?

• For patients who have had prior cholecystectomy and have a high probability of common bile duct stones, ERCP and sphincterotomy with DORMIA basket extraction is the preferred initial approach.

Thank you!