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SURGICAL AND INSTRUMENTAL

MANAGEMENT OF RETAIN CBD
STONE

Dr. M. Iqbal Rivai Sp.B KBD
Digestive Division, Dr.M.Djamil Hospital, West Sumatra

THE PROBLEM
• 15-20% of cholelithiasis with CBD stone
• After biliary tract surgery, 2-10% with residual stone
• 5-12% residual stone asymtomatic
• Dx post-op T-tube cholangiogram distressed both the
patient and the surgeon
• CBD re-exploration; mortality 3-28% and morbidity 20-30%

RISK FACTOR FOR RETAIN STONES • Dilated CBD • Gall bladder stone • Biliary stricture • Angulation of CBD • Previous open cholecystectomy • Periampullary diverticulum .

MANAGEMENT OF RETAIN STONE Depends on : • Expertise and facilities available • Age and general health of the patient • Size of stone • Whether a T tube is in place • Previous procedure .

an endoscopic extraction of CBD stones is the preferred approach • Extraction via T tube tract is safe and cost effective • ERCP/spincterotomy is a valuable method • Endo and laparoscopy : learning curve. adhesi : factors that limit endoscopic procedure . longer operative time. lack equipment • Recurrent stone after prior open exploration/ biliodigestive anastomose  re-exploration Stricture.GENERAL CONSIDERATION • If the GB has been removed previously.

T TUBE IN SITU.J.Surg • Perform after 12th day postoperative day • Infuse 1000 ml saline with 5000 unit heparin via T tube 24 h • Contraindicated if stone completely blocks CBD • Repeat every 4-5 day . Br. WHAT WE CAN DO ? • Saline or heparinized saline flushed For small stone and given glucagon (succes rate 50%) Motson.

T-TUBE IN SITU. WHAT WE CAN DO ? • Percutaneous extraction • Stone extraction via the T tube tract after 4-6 weeks 14F or larger T tube (Burhenne report : succes rate 95% in 661 patients) • Insert flexible catheter by Medi-Tech • Dormia stone basket .

DISSOLUTION • Ursodeoxycholic acid and Methyl-Tert-butyl-Ether • Cholesterol solvent • Into CBD for retain stone through T tube (14F or larger) • MTBE toxic to the liver and duodenal mucosa • For small-medium stone .

Ursodeoxycolic acid .Laser • ESWL • Dissolution .Methyl tert-buthyl ether (MBTE) • Long term stent • The choice of technique depends on local and the previous procedure . ENDOSCOPIC MANAGEMENT • Endoscopic sphincterotomy • Mechanical lithotripsy • Intraductal shockwave lithotripsy .Electrodydraulic .

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HPB Surgery (1995) • EPBD wtih dormia basket Large stone >20 mm require stone fragmentation • ES vs EPBD . ENDOSCOPIC SPHINCTEROTOMY (ES) & ENDOSCOPIC PAPILLARY BALLON DILATATION (EPBD) • Multi-center RCT : low clearance & high morbidity. when compared with open surgery • Schmitt reported ES succes rate 100% removal stone Schmitt CM. et al.

ENDOSCOPIC SPHINCTEROTOMY (ES) Reason for failure : • Large size of the stone • Technical difficulty in cannulation • Pariampullary diverticulum • Impacted stone Ballon cath + wire basket following sphincterotomy give good result .

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LAPAROSCOPIC EXP CBD .

MECHANICAL LITHOTRIPSY • Bile duct clearance 80-90% • For large stone >20 mm • Advantages .> 1 procedure GASTROINTESTINAL ENDOSCOPY. 65:6 2007 .Easy to use .Low cost .For larger and impacted stone • Disadvantages .Require stone capture .

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2011 . ES-LBD VS ML • ES-LBD is equally effective as ES-ML for large stone (>12 mm) • ES-ML the procedure of choice for stone >20mm • Post-operative complication significantly less in ES-LBD compared with ES-ML (4% vs 20%) • Cholangitis more common in ES-ML Stefanidis et al.

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ELECTROHYDROLIC LITHOTRIPSY (EHL) • Via peroral to fragment large bile duct • Best achieved under direct choledochoscopic and fluoroscopic visualization • EHL probe is commonly used in the SpyGlass system .

LASER LITHOTRIPSY • For complicated biliary stones using direct choledochoscopy • The second-line modality after ERCP • Require multiple sessions .

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OPEN DRAINAGE PROCEDURE When Why • Recurrent CBD stone • Fail to fragment stone • Impacted large CBD • Fail endoscopic and T stone tube stone extraction • Dilated CBD • Familiar with the local • Multiple CBD stone surgeon How • Facilities • Transduodenal sphincteroplasty • Choledochoduodenostomy • Choledochojejunostomy .

such as mechanical lithotripsy. laser. EHL.CONCLUSION • Retain billiary distressed both the patient and the surgeon • The choice of technique depends on Expertise and facilities available • Endoscopic techniques are effective for the treatment of retained CBD stones • Very large stones/complicated can be very challenging to manage • Another techniques. ESWL and Open drainage procedure .