Overview

New guidance written in 2016, commissioned by

the British Society of Gastroenterology
Builds on previous BSG guidance from 2008-
some recommendations kept, some replaced
Each recommendation categorised by strength of
evidence and strength of recommendation
This presentation focuses on recommendations
relevant to surgical practice. Some points, e.g.
regarding technical aspects of ERCP, excluded
Diagnosis
Patients with suspected CBDS should have
abdominal USS and LFTs. Normal results should
not preclude further investigation if clinical
suspicion remains high.
Strong recommendation/Low evidence

Patients with intermediate probability of CBDS

should have MRCP or EUS, depending on
individual patient factors and availability
Strong recommendation/Moderate evidence
Patients with suspected CBDS should have USS
and LFTs, with MRCP or EUS as the next step for
intermediate probability unless proceeding
directly to cholecystostomy with IOC or
laparoscopic ultrasound.
ERCP should be reserved for patients in whom
these assessments indicate a need for
endoscopic therapy
Weak recommendation/Low evidence
Operating in CBDS
Cholecystectomy is recommended for all
patients with CBDS and gall bladder stones
unless surgery is inappropriate
Strong recommendation/Moderate evidence

In patients undergoing cholecystectomy with an

intermediate-to-high probability of CBD stones,
but who have not had this confirmed by USS,
MRCP or EUS, an IOC or LUS is suggested.
Weak recommendation/Low evidence
Transcystic/transductal laparoscopic bile duct
exploration during cholecystectomy is as safe
and effective as perioperative ERCP, and is
associated with shorter stay. The two should be
considered equally valid options
Strong recommendation/High evidence
Recommendations
in Pancreatitis
Patients with pancreatitis of suspected/proven
biliary origin with associated cholangitis or
persistent biliary obstruction should have ERCP
within 72 hours of presentation
Strong recommendation/High evidence

All patients with gallstone pancreatitis should be

offered early laparoscopic cholecystectomy if it
is safe to operate
Strong recommendation/Moderate evidence
Cholecystectomy should be performed within 2
weeks of presentation with mild acute gallstone
pancreatitis, ideally within the same admission
Weak recommendation/Moderate evidence

Patients with gallstone pancreatitis not requiring

urgent (<72hr) ERCP should be considered for
elective ERCP and sphincterotomy if there is
retained CBDS on imaging, or if unsuitable for
cholecystectomy
Strong recommendation/Moderate evidence
Difficult Cases
If other endoscopic treatment options fail to
clear the duct, cholangioscopy-guided
electrohydraulic lithotripsy or laser lithotripsy
should be considered
Strong recommendation/Low evidence

Patients with acute cholangitis with sepsis or

who are failing to respond to antibiotics require
urgent biliary stenting, by ERCP or, if this is
impossible, percutaneous radiological drainage
Strong recommendation/Moderate evidence
Percutaneous radiological stone extraction and
open duct exploration should be reserved for
patients in whom endoscopic or laparoscopic
techniques fail or are impossible
Strong recommendation/Low evidence

Biliary stenting as a sole treatment for CBDS

should be used only when surgical risk is
prohibited or life expectancy is limited
Weak recommendation/Low evidence
Discussion Points
Key theme of this guidance is the need for stone
extraction in ALL patients with CBD stones where
possible
Supported by GallRiks study which found a 25.7%
prevalence of adverse events for patients with
retained CBD stones post-cholecystectomy, vs
12.7% of patients who underwent stone extraction
(Odds Ratio 0.44)
Discussion Points
Most recommendations relevant to general
surgeons already being followed by this team
Many recommendations key to general surgical
practice have only weak evidence, for example the
use of IOC. Lack of high-quality studies in surgical
management of CBD stones?
One strong recommendation with good evidence is
offering the use of laparoscopic bile duct
exploration as an alternative to ERCP- not currently
done here