Cbd stones

1. Biliary stone diseases
Mathew Philip
PVS Memorial hospital
Kochi

2. Prevalence of gallstones by age
and gender

3. Introduction
 Eleven to 21% of cholelithiasis have
concomitant CBDS at the time of surgery
 Majority of CBDS form in GB and then
migrate CBD
 Pass into the duodenum following the bile
flow
 May remain in the choledochus owing to
the smaller diameter at the Vater papilla

4. Clinical presentation
 Asymptomatic
 Colicky pain
 Cholecystitis
 Biliary obstruction
 Ascending cholangitis
 Acute Biliary pancreatitis

5. CBD stones - Endotherapy
 Diagnosis
 US,MRCP, EUS and ERC
 Endoscopic retrograde cholangiography
(ERC) changed the approach to CBDS

6. Role of EUS
 Diagnosis of CBDS
 Comparable to MRC
 More sensitive for
 Biliary microcalculi
 Small stone impaction at ampulla
 Biliary sludge
 Reduce ERC interventions

8. Outline
 Standard treatment of CBD stones
 Define Difficult Bile duct stone
 Factors associated with difficult CBD stones
 Treatment strategies of difficult CBD stones

9. Outline
 Standard treatment of CBD stones
 Define Difficult Bile duct stone
 Factors associated with difficult CBD stones
 Treatment strategies of difficult CBD stones

10. Standard treatment of CBD stnes

14. Standard Treatment of
CBD stones

15. Outline
 Standard treatment of CBD stones
 Define Difficult Bile duct stone
 Factors associated with difficult CBD stones
 Treatment strategies of difficult CBD stones

16. Difficult CBD Stone
 Commonly refers to a stone > 15 mm in diameter
 Usually unable to make ES larger than 15 mm
 Stones < 15 mm may be considered difficult if:
 Proximal to stricture
 Narrow intrapancreatic segment
 Impacted
 Multiple
 Intrahepatic
 Billroth II reconstruction
 ES length is limited – e.g., periampullary diverticulum

17. Outline
 Standard treatment of CBD stones
 Define Difficult Bile duct stone
 Factors associated with difficult CBD stones
 Treatment strategies of difficult CBD stones

18. The variables affecting the success of stone
extraction
 Stone size and shape
 Bile duct diameter
 Bile duct geometry
 Composition of the stone
 Bile duct strictures distal to the stone

19. Endoscopic technical difficulty of
CBD Stones
 Older age (>65 years)
 Previous gastrojejunostomy
 Larger CBD stone (≥ 15 mm)
 Impacted CBD stone
 Use of mechanical lithotripsy
 Short length of the distal CBD arm (<36mm)
 Acute distal CBD angulation (<135 degrees)
 Relative narrowing of distal CBD
GIE 2007; 66:1154-60

21. Reasons for unsuccessful
CBD stone removal
 Anatomic obstacles to cannulation
 Postoperative states
 Billroth II gastroenterostomy
 Roux-en-Y anastomosis
 Anastamotic strictures
 Ampullary or duodenal tumor mass
 Scared duodenum from prior PUD
 Periampullary diverticulum
 Ampullary edema or inflammation

22. Outline
 Standard treatment of CBD stones
 Define Difficult Bile duct stone
 Factors associated with difficult CBD stones
 Treatment strategies of difficult CBD stones

23. Principle for treatment
Difficult biliary stone
 Decrease stone size
 Larger CBD orifice

24. Principle for treatment
Difficult biliary stone
 Decrease stone size
 Larger CBD orifice

25. Endoscopic Management of
Large Bile Duct Stones
 Mechanical lithotripsy
 Intraductal shockwave lithotripsy
 Electrohydraulic
 Laser
 Extracorporeal shockwave lithotripsy
 Dissolution
 MTBE
 Monooctanoin
 Long term stents

26. Endoscopic Management of
Large Bile Duct Stones
 Mechanical lithotripsy
 Intraductal shockwave lithotripsy
 Electrohydraulic
 Laser
 Extracorporeal shockwave lithotripsy
 Dissolution
 MTBE
 Monooctanoin
 Long term stents

27. Mechanical lithotripsy
 Integrated
 Salvage

28. Mechanical Lithotripsy
 Advantages
 Relatively easy to use
 Relatively low cost
 Prevents stone impaction
 Can be done at initial ERCP
 Disadvantages
 Requires stone capture
 Very hard stones may not fragment
 Several baskets may be required for each patient

31. Soehendra Mechanical Lithotriptor

32. Mechanical lithotripsy- Salvage

33. Principle for treatment
Difficult biliary stone
 Decrease stone size
 Larger CBD orifice

34. Large Balloon
Dilatation of Sphincter

35. Bile Duct Stones
Failed Mechanical Lithotripsy
ESWL
Percutaneously Surgery
Cholangioscope
- Laser
- EHL
Stent
Dissolve

36. Cholangioscope
 Mother baby scope
 Two operators
 Fargile
 High repair costs
 No dedicated irrigation channel
 Limited two way steering
capability
 Spyglass
 Single operator
 Four way steering capability
 Independent irrigation channel
 Diagnostic and therapeutic
capabiities

37. Mother-Baby Scope System

38. Spyglass

39. Spyglass
10 Fr catheter
Guidewire
Optical fiber
Direction
dials +
locks
Irrigation port

41. Cholangioscopy and
Stone fragmentation

42. Endoscopic management of
Calculous cholecystitis
 Comorbidities
 Elderly
 Trans papillary GB stenting / drainage
 EUS guided cholecystoduodenostomy

43. Conclusions
 Biliary lithiasis affects 10% to 20% of
general population
 CBDS in up to 20%
 Endoscopic removal successful in 80-90%
using standard techniques
 EUS has an important role and avoids
unnecessary ERC

44. Conclusions
 Stone location, stone size, and bile duct
features may render stones non
extractable using standard retrieval
techniques
 Balloon sphincteroplasty helps in
extracting bigger stone
 Difficult stones mechanical lithotripsy is
easiest and cheapest, if stone can be
captured in basket

45. Conclusions
 Using all endoscopic and ancillary
techniques, stone clearance rate ~ 97%
 Direct cholangioscopic stone removal
could achieve near complete stone
removal except in intra hepatic stones
 CBDS management is multidisciplinary
 Tailored on available resources and
expertise