← All decks
The first 25 slides, exactly as they appear. The full deck has 181 content slides.
General Surgery
Choledocholithiasis and Cholangitis
Built from Maingot's Abdominal Operations
What’s inside
16 sections · 181 slides
Overview
- Scope of this presentation
Classification and Epidemiology
Where bile duct stones come from, and how common they are
- Anatomy of the biliary tree
- Lower bile duct and the duodenum
- 15%
- Cost of gallstones and frequency of duct stones
- Secondary and primary bile duct stones
- Secondary stones and how cholesterol stones form
- Risk factors for cholesterol gallstones
- Black pigment and primary brown pigment stones
- Bacteria in stone formation and intrahepatic stones
- Pathogenesis of intrahepatic stones
- Controversy over the role of parasites
Clinical Presentation and Natural History
From a silent stone to sepsis and cirrhosis
- Silent stones and the symptoms they cause
- Complications of the clinical course
- Bacterial biofilm on bile duct stones
- From obstruction to bacterial sepsis
- Natural history of an untreated duct stone
- Physical examination findings
- Blood tests in choledocholithiasis
- Other laboratory clues and their limits
Three Clinical Windows
Duct stones are met before, during or after gallbladder surgery
- Three settings in which duct stones are met
- Why the three windows matter
Preoperative Assessment
Predicting which patient actually harbours a duct stone
- Limits of clinical diagnosis
- Risk factors and independent predictors
- Transcutaneous ultrasound
- Ultrasound and duct dilatation as predictors
- Gallbladder stone size as a predictor
- Predictive values of ultrasound and blood tests
- Combining clinical, laboratory and ultrasound findings
- Treatment pathway for suspected duct stones before surgery
- Reading the preoperative algorithm
Endoscopic Retrograde Cholangiopancreatography
Diagnosis and stone clearance through the mouth
- Development of ERCP
- What ERCP is
- Accuracy of ERCP for duct stones
- Stone in the lower bile duct seen at cholangiography
- Reading the cholangiogram
- Diagnosis and treatment in one sitting
- Stone extraction seen through the endoscope
- Balloon sweep of a stone out of the bile duct
- Sphincterotomy
- Balloon sphincteroplasty
- Choosing between a basket and a balloon
- Difficult extraction and abandoned dissolution therapy
- Mechanical lithotripsy
- Results and limits of mechanical lithotripsy
- Intraductal shock wave lithotripsy
- Safety devices and availability
- Results of electrohydraulic lithotripsy
- Extracorporeal shock wave lithotripsy
- Other shock wave experience
- Large-balloon dilatation of the lower bile duct
- Escalating treatment for a difficult duct stone
- Temporising with drainage and stents
- Long-term stenting as a definitive plan
Complications of ERCP
A safe procedure with well-defined, occasionally lethal risks
- Mortality after ERCP and how to read the figures
- 0.3-0.6%
- Prophylactic antibiotics before ERCP
- Post-ERCP pancreatitis: definition and risk factors
- The highest-risk group and how to protect it
- Drug prophylaxis against post-ERCP pancreatitis
- Nitrates and pancreatic stents
Imaging Before Intervention
Computed tomography, MRCP, endoscopic ultrasound and the percutaneous route
- Rationale for imaging before ERCP
- Computed tomography for duct stones
- Computed tomography compared with endoscopic ultrasound
- Principle of magnetic resonance cholangiopancreatography
- Duct stones on magnetic resonance cholangiopancreatography
- Capability of modern MRCP
- Reported accuracy of MRCP
- Limitations of MRCP and of ERCP
- Endoscopic ultrasound
- Safety and accuracy of endoscopic ultrasound
- Endoscopic ultrasound compared with MRCP
- Percutaneous transhepatic cholangiography
- Percutaneous stone removal
- Transhepatic cholangioscopy and lithotripsy
Cholecystectomy After Duct Clearance
Does the gallbladder still have to come out?
- Argument for removing the gallbladder
- Concern about long-term cancer risk
- Evidence for leaving the gallbladder in place
- Longer follow-up and gallbladder status
- Practical position on cholecystectomy after duct clearance
Stones Found at Operation
Cholangiography, ultrasound and duct exploration during cholecystectomy
- Three groups arriving in the operating room
- Intraoperative cholangiography
- Fluoroscopy and the accuracy of laparoscopic cholangiography
- Routine versus selective cholangiography
- Intraoperative ultrasound
- Natural history of stones found at cholangiography
- Implication for treating a positive cholangiogram
- Treatment pathway for duct stones found at cholecystectomy
- Reading the intraoperative algorithm
- Open common bile duct exploration
- Place of open exploration today
- Rise and results of laparoscopic duct exploration
- Transcystic and transductal access to the duct
- Opening and clearing the duct laparoscopically
- Instruments and closure of the choledochotomy
- T-tube compared with primary closure
- When laparoscopic duct exploration fails
- Intraoperative ERCP
- Results of intraoperative ERCP
- Arguments for intraoperative rather than postoperative ERCP
Stones After Cholecystectomy
Retained and recurrent duct stones
- First-line treatment after cholecystectomy
- Retained stones after gallbladder removal
- Reading this cholangiogram
- Options when ERCP is not possible
Surgical Biliary Drainage
Sphincteroplasty, choledochoduodenostomy and choledochojejunostomy
- Indications for a surgical drainage procedure
- Three surgical drainage operations
- Indications for transduodenal sphincteroplasty
- Exposing the ampulla for sphincteroplasty
- Completing the sphincteroplasty
- Outcomes after transduodenal sphincteroplasty
- Origins and indications of choledochoduodenostomy
- Planning a choledochoduodenostomy
- Technique of choledochoduodenostomy
- Morbidity, mortality and cholangitis after the join
- Sump syndrome
- Preventing sump syndrome
- Other complications and long-term results
- Ten-year comparison of the two duct-widening operations
- What symptoms after the join meant
- A second comparison of the two operations
- Choledochojejunostomy
- Outcomes of the duct-to-jejunum join
- Arguments for and against stenting a biliary anastomosis
- Results without stents and what predicts failure
- Laparoscopic and robotic drainage procedures
- Summary of choledocholithiasis management
Cholangitis
Infected bile behind a blocked duct
- Definition of cholangitis and the defences it defeats
- Loss of defence when the duct is blocked
- From rising duct pressure to septicaemia
- Which obstructions cause cholangitis
- Other causes of cholangitis
- Organisms cultured in cholangitis
- Charcot's triad and Reynold's pentad
- Examination and laboratory findings
- Imaging in suspected cholangitis
- Initial supportive treatment
- Choice of antibiotics
- Duration of antibiotic treatment
- Drainage as the mainstay of treatment
- Endoscopic drainage as first choice
- Endoscopic compared with surgical decompression
- Choosing the endoscopic technique
- Percutaneous and surgical drainage in cholangitis
- Cholecystectomy after an attack of cholangitis
- Where cholecystectomy does not help
Hepatolithiasis
Stones formed in the ducts inside the liver
- Definition and changing pattern of hepatolithiasis
- ~1%
- Causes and stone composition
- Clinical course and cancer risk
- Diagnosis of hepatolithiasis
- Principles and goals of treatment
- Hepatic resection for localised disease
- Effect of duct stricture on results of hepatectomy
- Limits of resection and clearance rates
- Hepaticojejunostomy and building an access point
- Percutaneous choledochoscopic stone removal
- Other percutaneous and laparoscopic results
- North American experience and outlook
Key Points
What to carry away from this topic
- Key points: the stones themselves
- Key points: making the diagnosis
- Key points: treatment
- Key points: cholangitis and liver stones
References
Sources cited in this topic
- References
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- References (continued)
- Maingot's Abdominal Operations, 12th Edition