Management of Gallstones and Associated Complications

Transcription

1 GENERAL SURGERY BOARD REVIEW MANUAL PUBLISHING STAFF PRESIDENT, PUBLISHER Bruce M.White Management of Gallstones and Associated Complications EXECUTIVE EDITOR Debra Dreger SENIOR EDITOR Miranda J. Hughes, PhD ASSISTANT EDITOR Melissa Frederick EDITORIAL ASSISTANT Rita E. Gould SPECIAL PROGRAMS DIRECTOR Barbara T.White, MBA PRODUCTION DIRECTOR Suzanne S. Banish PRODUCTION ASSOCIATES Tish Berchtold Klus Christie Grams PRODUCTION ASSISTANT Mary Beth Cunney ADVERTISING/PROJECT MANAGER Patricia Payne Castle Series Editor: Christopher R. McHenry, MD, FACS, FACE Director, Division of Surgery MetroHealth Medical Center Associate Professor of Surgery Case Western Reserve University School of Medicine Cleveland, OH Contributing Author: Christopher P. Brandt, MD Associate Professor of Surgery Case Western Reserve University School of Medicine Attending Surgeon MetroHealth Medical Center Cleveland, OH Table of Contents Introduction NOTE FROM THE PUBLISHER: This publication has been developed without Pathophysiology of Gallstone-Related Diseases involvement of or review by the American Board of Surgery. Management of Cholelithiasis Choledocholithiasis Endorsed by the Association for Board Review Questions Hospital Medical Detailed Answers Education The Association for Hospital Medical Education References endorses HOSPITAL PHYSICIAN for the purpose of presenting the latest developments in medical education as they affect residency programs and clinical hospital practice. Cover Illustration by Scott M. Holladay Copyright 2001, Turner White Communications, Inc., 125 Strafford Avenue, Suite 220, Wayne, PA , All rights reserved. No part of this publication may be reproduced, stored in a retrieval system, or transmitted in any form or by any means, mechanical, electronic, photocopying, recording, or otherwise, without the prior written permission of Turner White Communications, Inc. The editors are solely responsible for selecting content. Although great care is taken to ensure accuracy, Turner White Communications, Inc. will not be liable for any errors of omission or inaccuracies in this publication. Opinions expressed are those of the authors and do not necessarily reflect those of Turner White Communications, Inc. General Surgery Volume 6, Part 3 1

2 GENERAL SURGERY BOARD REVIEW MANUAL Management of Gallstones and Associated Complications Contributing Author: Christopher P. Brandt, MD I. INTRODUCTION Management of cholelithiasis and associated complications is a frequent problem encountered in general surgery. Cholelithiasis affects approximately 10% to 15% of adults in the United States, with an estimated 1 million new cases diagnosed annually. Although most patients with gallstones remain asymptomatic, a wide range of conditions secondary to cholelithiasis can develop, ranging from limited episodes of pain to potentially lethal cholecystitis, pancreatitis, cholangitis, or carcinoma. 1 Treatment for patients with gallstones has changed dramatically during the past 10 years and may now involve multiple nonsurgical specialties. This review will present the common manifestations of cholelithiasis and discuss potential management options and outcomes. Sample board review questions with detailed answers are provided at the end of this manual for self-assessment. II. PATHOPHYSIOLOGY OF GALLSTONE- RELATED DISEASES Most gallstones in humans are primarily composed of cholesterol, although occasionally pigment stones can develop, which are usually related to hemolytic disease. Well-known risk factors for cholesterol stone formation include female sex, multiparity, obesity, and rapid weight loss. The incidence is also high in certain ethnic groups, such as Native Americans. Formation of cholesterol gallstones requires supersaturation of bile with cholesterol, accelerated nucleation of cholesterol crystals, and gallbladder hypomotility. 2 The supersaturation of bile is usually caused by cholesterol hypersecretion, which occurs via multiple mechanisms. Cholesterol secretion into bile increases with age and after rapid weight loss. Excessive cholesterol synthesis occurs in obese or pregnant patients and is also seen with estrogen use. Pregnant women also have a decreased gallbladder emptying time. Cholesterol supersaturation, especially when coupled with excess levels of the secondary bile salt deoxycholate, causes gallbladder inflammation with secretion of procrystallizing proteins (ie, immunoglobulins and mucous glycoproteins). 2 This condition leads to crystal formation, a process promoted by hypomotility of the gallbladder. Most symptoms and clinical manifestations of gallstones are associated with an obstruction of the cystic duct or common bile duct (CBD). This blockage may be intermittent, partial, or complete. Patients with a temporary cystic duct obstruction commonly present with intermittent pain or biliary colic, believed to result from gallbladder distention secondary to the duct obstruction. Acute cholecystitis is most often associated with stagnant bile that develops from cystic duct obstruction and secondary mucosal inflammation, a release of inflammatory mediators, alterations in perfusion, and secondary infection. Cholangitis occurs with CBD obstruction accompanied by biliary stasis and eventual infection with bacteria from the portal circulation passing from the hepatic sinusoids. Gallstone pancreatitis results from passage of a CBD stone through the sphincter of Oddi and into the duodenum. It is unclear how this leads to pancreatitis; however, the condition may be related to bile reflux into the pancreatic duct and to ductal hypertension with ongoing pancreatic secretion against the obstruction. III. MANAGEMENT OF CHOLELITHIASIS ASYMPTOMATIC CHOLELITHIASIS Asymptomatic cholelithiasis is a common occurrence, with most patients (70% to 80%) remaining free of symptoms during their lifetime. 3 An estimated 2% to 4% of asymptomatic patients will develop symptoms each year, and only 10% of those patients present with serious complications. 4 The average patient with asymptomatic cholelithiasis often does not require therapy 2 Hospital Physician Board Review Manual

3 because the rate of symptomatic progression is low and, if it does occur, generally presents as an uncomplicated episode of pain. However, the physician must be sure that persons with cholelithiasis are truly asymptomatic. The disorder may cause atypical symptoms, and a diagnosis can be difficult to pinpoint. Select indications exist for prophylactic cholecystectomy, including patients with sickle cell disease and associated cholelithiasis, children with cholelithiasis, and patients with a porcelain gallbladder, considered to be a premalignant condition. Incidental cholecystectomy should also be considered if cholelithiasis is discovered at the time of other clean contaminated or contaminated surgical procedures. SYMPTOMATIC CHOLELITHIASIS Patients who develop pain secondary to gallstones are likely to have recurrent symptomatic episodes; therefore, in most patients, symptomatic cholelithiasis is an indication for therapy. Typically, bilary pain is relatively severe and episodic, occurring in the epigastric region or right upper quadrant and often lasting for several hours. The options for treatment of cholecystolithiasis include dissolutional therapy, cholecystectomy (either laparoscopic or open), or extracorporeal shock-wave lithotripsy (ESWL). A comparison of these options is outlined in Table 1. Dissolutional Therapy Dissolutional therapy can be performed using oral bile acids (ie, chenodeoxycholic acid, ursodeoxycholic acid) or direct-contact agents (primarily methyl tertbutyl ether). Direct-contact dissolution requires percutaneous access to the gallbladder and is rarely indicated. The highest incidence of successful dissolution occurs in nonobese patients with cholesterol stones less than 10 mm in diameter and a functioning gallbladder. However, less than 33% of patients eligible to receive dissolution therapy meet all of these criteria. Oral dissolution therapy also has a major drawback, in that the diseased gallbladder and lithogenic bile remain intact, thus making stone recurrence an ongoing possibility. 5 Treatment with oral dissolution, therefore, is limited to a small percentage of patients, who are generally older and have prohibitive risks for operation. The results, side effects, and costs associated with oral dissolutional therapy are outlined in Table 2. Extracorporeal Shock-Wave Lithotripsy The use of ESWL is affected by many of the inherent limitations noted with oral dissolution therapy. Candidates for ESWL should have fewer than 3 stones Table 1. Comparison of Therapies for Cholelithiasis Gallbladder Extirpation Gallstone Ablation Open Lap Dissolu- Variable Chol Chol ESWL tion Applicability, %* Rate of stone clearance, % Mortality, % < 1 < Overall morbidity, % Bile duct injury, % Gallstone recur- 0 0 < 50 ~ 50 rence, % Hospital stay, days < 1 0 Disability, days ESWL = extracorporeal shock-wave lithotripsy; Lap Chol = laparoscopic cholestectomy; Open Chol = open cholestectomy. *Percentage of patients who can receive the procedure. each less than 2 cm in diameter and should have a functioning gallbladder; however, only about 15% of symptomatic patients meet these criteria. In addition, concomitant oral dissolution therapy is often required, and the lithotripsy machines are extremely expensive. Because of these limitations, use of ESWL has essentially been supplanted by laparoscopic cholecystectomy. Cholecystectomy After its initial description in 1987, 6 laparoscopic cholecystectomy rapidly became the treatment of choice for symptomatic cholelithiasis. When compared with open cholecystectomy, advantages to laparoscopy include less postoperative pain, a shortened hospital stay, earlier return to activity, and improved cosmesis. However, there are some complications inherently unique to or increased with the laparoscopic approach. Vascular or visceral injury can occur as complications associated with obtaining access to the peritoneal cavity. Hemorrhage caused by needle or trocar placement most commonly originates from injury to the epigastric vessels, although major retroperitoneal bleeding can result from injury to the aorta or vena cava. In addition, bowel injuries have been reported in 0.1% to 0.7% of patients who underwent laparoscopic cholecystectomy. Such problems can be minimized with the routine use of an open method for initial trocar insertion and creation of pneumoperitoneum versus Veress needle insertion. With the open approach, bowel injuries should General Surgery Volume 6, Part 3 3

4 Table 2. Oral Bile Acid Dissolution Therapy for Cholelithiasis Chenodeoxycholic Ursodeoxycholic Variable Acid Acid Optimal dosage 8 13 mg/kg per day 8 10 mg/kg per day Complete 7% 70% 17% 65% dissolution rate Stone recurrence 50% 50% (5-year) Side effects Diarrhea 34% 41% 0% 4% Hepatitis 3% 9% 0% 4% Cost* $1500/yr $1700 *For 1 2 years of therapy. Adapted with permission from Gholson CF, Sittig K, McDonald JC: Recent advances in the management of gallstones. Am J Med Sci 1994; 307:296. occur in less than 0.1% of cases. 7 Trocar site complications primarily consist of hematoma, incisional hernia, and infection. Incisional hernias are infrequent with the use of smaller-sized trocars and closure of defects larger than 5 mm. Wound infection occurs in 1% to 2% of cases but is usually a minor concern. Pneumoperitoneum can result in hypercapnia and decreased venous return; however, this complication may be easily controlled with ventilatory management and maintenance of intra-abdominal pressures less than 15 mm Hg. The intraperitoneal spillage of gallstones is common with laparoscopic cholecystectomy. Retained stones are innocuous in most cases but have been reported to cause intra-abdominal abscess and erosion into adjacent structures. Therefore, reasonable attempts to remove spilled stones should be made at the time of surgery. Bile Duct Injuries The most serious complications associated with laparoscopic cholecystectomy are bile duct injuries and biliary leaks. Reported rates of CBD injury in laparoscopic procedures have ranged from 0.2% to 1.0%. These varying rates are partly related to surgeon experience; however, biliary injury continues to occur more frequently in laparoscopic versus open cholecystectomy. 8 Although still relatively unusual, bile duct injury can result in significant morbidity and mortality and is associated with a high risk of litigation. Postoperative bile leaks most commonly develop from an inadequate cystic duct ligation or a disruption of a small accessory duct in the gallbladder bed. Bile leakage usually presents with postoperative abdominal pain, fever, or malaise. In these situations, the diagnostic goal is to determine whether an intraperitoneal fluid collection is present. If fluid collection is detected on computed tomography (CT) scan or ultrasound, percutaneous drainage should be performed. If bile is obtained from the drainage, bile scintigraphy can determine whether the leak is ongoing. If such a leak exists, endoscopic retrograde cholangiopancreatography (ERCP) should be performed to confirm the source of the leak. Although cystic duct or small accessory bile duct leaks can resolve with drainage alone, temporary CBD stent placement shortens the time to resolution and need for external drainage. Major ductal injury most often occurs secondary to incorrect identification of ductal anatomy or as a result of electrocautery injury. Less than 50% of these injuries are recognized at the time of surgery. Risk factors for bile duct injury include inadequate or misdirected retraction of the gallbladder, surgeon inexperience, excessive use of cautery, dissection too far away from the gallbladder cystic duct junction, and presence of severe acute or severe chronic cholecystitis. Routine intraoperative cholangiography has not appeared to significantly decrease the incidence of ductal injury but can lead to earlier recognition, more simple repair, and reduction in the incidence of severe high duct injuries. 9 When an injury is recognized during surgery, conversion to an open procedure for immediate repair is indicated if the surgeon has the appropriate expertise. If not, external drainage and transfer to a specialized hepatobiliary center is appropriate. A partial CBD injury can often be managed with simple T-tube placement, whereas duct transections are best managed with hepaticojejunostomy, a procedure that can lower longterm stricture risk when compared with primary repair or choledochoduodenostomy. Classification system. Strasberg et al 10 have proposed a classification system for duct injury after laparoscopic cholecystectomy (Figure 1). Type B and C injuries involve aberrant right hepatic ducts, which are seen in up to 5% of patients. Specific treatment is not necessary in asymptomatic patients when the affected segment is small. Type D and E injuries involve the main CBD and can range from partial injury to complete transection or delayed stricture. Most patients with type E injuries that are not immediately recognized present postoperatively with jaundice; patients with type D injuries usually develop an external bile fistula. Patients with postoperative jaundice should undergo ERCP to rule out retained CBD stones, biliary 4 Hospital Physician Board Review Manual

5 leak, or CBD stenosis or transection. Percutaneous transhepatic cholangiography may be necessary to outline the proximal biliary system in cases of ductal incontinuity. Select cases of stenosis may be managed with endoscopic balloon dilation and prolonged intraluminal stenting. This procedure is most successful when the stenosis is short (< 1 cm) or partial. The remaining cases of stenosis or transection should be treated by Roux en-y hepaticojejunostomy with direct mucosa-to-mucosa anastomosis. Long-term results following repair with hepaticojejunostomy are good but still associated with a 5% mortality and a 10% to 25% risk of recurrence. A B ACUTE CHOLECYSTITIS Cholecystectomy is the treatment of choice for most patients with acute cholecystitis and can be accomplished laparoscopically in 80% to 90% of cases. Typical symptoms of acute cholecystitis include persistent right upper quadrant or epigastric pain, fever, nausea, and tenderness on abdominal palpation. Cholecystectomy is more likely to be successful earlier in the inflammatory course; thus, it is not beneficial to delay surgery. However, laparoscopy can certainly be more difficult when inflammation is pronounced and may require decompression of the gallbladder, use of larger-toothed graspers, and placement of additional trocars. Because the reported incidence of ductal injury is higher with acute cholecystitis, conversion to an open procedure is often a sound surgical decision if the ductal anatomy cannot be safely delineated or if inflammation or associated hemorrhage precludes safe laparoscopic dissection. Select patients at high risk for surgery (eg, critically ill patients in the intensive care unit) can be managed safely and effectively with percutaneous transhepatic cholecystostomy, which has a reported success rate of 73% to 100%. 11 Interval cholecystectomy can then be considered if the patient stabilizes. CHOLELITHIASIS AND PREGNANCY The management of cholelithiasis in pregnant patients can be challenging. The incidence of symptomatic cholelithiasis, usually consisting of biliary colic or acute cholecystitis, is 0.1% to 0.2%. The primary treatment strategy for biliary colic in pregnancy involves the attempt to control symptoms with conservative management (eg, use of analgesics, a reduced-fat diet, and reduction in meal size). However, 30% to 40% of symptomatic pregnant patients will have recurrent biliary colic that is refractory to medical therapy. If surgery is required, the physician should attempt to delay the procedure until the second trimester, when fetal development is more advanced, the risk of spontaneous labor is minimized, C > 2 cm < 2 cm E 3 E 1 E 2 E 4 Figure 1. A new classification of laparoscopic injuries to the biliary tract. Type A to E injuries are shown.type A injuries originate from small bile ducts that are entered in the liver bed or from the cystic duct.type B and C injuries almost always involve aberrant right hepatic ducts.type A, C, D, and some E injuries may cause bilomas or fistulae. Type B and other type E injuries occlude the biliary tree, and bilomas do not occur.type E injuries are subdivided according to the Bismuth classification. Type E 1 and E 2 injuries are classified by the length of common hepatic duct remaining after injury (ie, < 2 cm in type E 1 and > 2 cm in type E 2 ). Adapted with permission from Strasberg SM, Hertl M, Soper NJ: An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180: D E 5 General Surgery Volume 6, Part 3 5

6 and uterine size is more amenable to a laparoscopic approach. The current consensus among surgeons is that laparoscopy is safe in pregnant patients and that laparoscopic cholecystectomy is the procedure of choice. A recent review of reported experience after laparoscopic cholecystectomy in pregnancy showed survival rates of 100% for mothers and 96% for their fetuses, although the incidence of premature labor was 12.5% in patients undergoing surgery in the third trimester. 12 The general treatment goals for acute cholecystitis in pregnant patients are similar to treatment goals for symptomatic cholelithiasis, with initial attempts at nonoperative management and postpartum cholecystectomy. Cholecystectomy should not be delayed, however, if initial attempts at nonoperative therapy do not result in prompt clinical improvement. IV. CHOLEDOCHOLITHIASIS CBD stones may form de novo in the bile ducts or arise in the gallbladder and migrate through the cystic duct. The incidence of CBD stones is reported to be 7% to 20% in patients undergoing cholecystectomy and increases with patient age and duration of symptoms. 13 Patients with CBD stones may be asymptomatic or present with obstructed jaundice, cholangitis, or acute pancreatitis. Methods of diagnosing CBD stones include percutaneous transhepatic cholangiography; ERCP; magnetic resonance cholangiography; or intraoperative cholangiography or ultrasound, either endoscopic, laparoscopic, or transcutaneous. Before the advent of laparoscopic cholecystectomy, management decisions regarding CBD stones were generally straightforward. Stones discovered at the time of surgery were removed by open choledochotomy, with high success rates and low morbidity. Mortality, however, approached 10% in patients older than 70 years or in patients with acute cholecystitis. ERCP and stone extraction with or without ductal drainage was used to treat patients with retained CBD stones or those presenting with jaundice or cholangitis. Decision making has become more complex since laparoscopy was introduced as a valid method of treating cholelithiasis. Physicians managing patients with known or suspected stones now have a number of therapeutic options at their disposal. To optimize individual patient care, it is imperative that the physician understand the risks, costs and outcomes, local availability, and necessary expertise associated with these endoscopic and surgical techniques. SUSPECTED OR DETECTED CHOLEDOCHOLITHIASIS The development of laparoscopic cholecystectomy changed the management of patients with CBD stones suspected preoperatively or detected at the time of surgery. In many institutions, preoperative ERCP became a standard approach for patients with suspected CBD stones. Similarly, postoperative ERCP was performed when bile duct stones were detected during a laparoscopic procedure. There are significant disadvantages to this approach; predictors of CBD stones are often inaccurate, and preoperative ERCP based on clinical signs, symptoms, and laboratory data identifies stones in only 35% to 45% of patients. In one large study of patients undergoing routine intraoperative cholangiography, patients with 4 abnormal liver function tests showed a 43% incidence of CBD stones, compared with an incidence of 7% when all liver function tests were normal. 14 The most reliable indicators of CBD stones are cholangitis, jaundice, or evidence on ultrasonography. 15 Magnetic resonance cholangiography is a noninvasive modality that provides an image of the biliary tree without the need for contrast material. Although experience with this imaging technique is relatively new and limited, a sensitivity rate of greater than 90% has been shown. 16 Lack of widespread availability and increased cost currently limit magnetic resonance cholangiography in the detection of choledocholithiasis; however, this technique may become an important and more frequently used modality in the future. For patients with cholelithiasis and CBD stones suspected preoperatively, the basic management options include a 1-step or 2-step approach. The 1-step approach consists of confirmation by intraoperative cholangiogram and treatment at the time of cholecystectomy. The 2-step approach consists of preoperative ERCP followed by laparoscopic cholecystectomy and postoperative ERCP when stones are found during surgery. 17 A 1-step treatment of cholelithiasis and CBD stones is attractive because it can avoid the associated morbidity, cost, and increased hospital stay associated with a second procedure. Traverso 18 has demonstrated a clear advantage for laparoscopic common bile duct exploration (CBDE), which increased the cost of care by only 14%, over laparoscopic cholecystectomy alone when compared with a 90% to 100% increased cost with addition of ERCP, papillotomy, and stone removal. Representative algorithms for the 1-step and 2-step procedures are outlined in Figures 2 and 3, respectively. For patients found to have CBD stones at the time of cholecystectomy, decisions regarding which procedure to use depend on several factors, including surgical 6 Hospital Physician Board Review Manual

7 Patient with suspected choledocholithiasis Intraoperative cholangiography No CBD stones CBD stones Laparoscopic cholecystectomy Stone < 0.9 mm Stone > 0.9 mm LC + LTCE Laparoscopic choledochotomy Open CBDE Successful Retained stones Figure 2. One-step approach to the patient with suspected choledocholithiasis. CBD = common bile duct; CBDE = common bile duct exploration; LC = laparoscopic cholecystectomy; LTCE = laparoscopic transcystic common bile duct exploration. Adapted with permission from Rosenthal RJ, Rossi RL, Martin RF: Options and strategies for the management of choledocholithiasis. World J Surg 1998;22:1129. Patient with suspected choledocholithiasis Nonresolving pancreatitis Jaundice Cholangitis Poor operative risk Yes ERCP or ERS, stone extraction No Laparoscopic intraoperative cholangiography Retained stones Laparoscopic cholecystectomy Stones cleared Postoperative ERCP, ERS, or stone extraction Yes Retained stones No Laparoscopic cholecystectomy Open CBDE or percutaneous stone extraction Done Figure 3. Two-step approach to the patient with suspected choledocholithiasis. CBDE = common bile duct exploration; ERCP = endoscopic retrograde cholangiopancreatography; ERS = endoscopic retrograde sphincterotomy. Adapted with permission from Rosenthal RJ, Rossi RL, Martin RF: Options and strategies for the management of choledocholithiasis. World J Surg 1998;22:1129. expertise, endoscopic expertise and availability, nature of the patient s condition (eg, number, location, and morphology of stones), and overall cost-effectiveness. Current data support various alternative treatment regimens. Primary treatment options for these patients include laparoscopic CBDE, open CBDE, or postoperative ERCP with sphincterotomy. The advantages and disadvantages of these approaches are outlined in Table 3. Endoscopic Retrograde Cholangiopancreatography Since its introduction in 1974, ERCP with stone extraction has become a widely used and accepted treatment for choledocholithiasis. The primary reasons for the dramatic increase in the use of ERCP have been the lack of techniques for laparoscopic CBDE and a strong impetus to avoid conversion from a laparoscopic to an open operation. During the past decade, however, techniques for laparoscopic CBDE have been General Surgery Volume 6, Part 3 7

8 Table 3. Comparison of the 1- and 2-Step Approaches for Evaluating Choledocholithiasis One-step approach: LC + LTCE Advantages Lower costs Shorter hospital stay Potentially decreased morbidity Disadvantages More technically demanding Requires expensive equipment Longer operating time Increased operating room cost Two-step approach: LC + preoperative or postoperative ERCP with sphincterotomy Advantages Shorter operating time Less technically demanding Requires less equipment Disadvantages Longer hospital stay Increased total costs Potentially increased morbidity Two separate procedures ERCP = endoscopic retrograde cholangiopancreatography; LC = laparoscopic cholecystectomy; LTCE = laparoscopic transcystic common bile duct exploration. Adapted with permission from Rosenthal RJ, Rossi RL, Martin RF: Options and strategies for the management of choledocholithiasis. World J Surg 1998;22:1129. introduced and, in experienced hands, have resulted in high rates of successful duct clearance. 19 ERCP remains a useful option when CBD stones are found at the time of cholecystectomy; ERCP can be performed intraoperatively or postoperatively. The rate of successful duct clearance is dependent on the endoscopist s experience and expertise. Ability to achieve stone clearance ideally ranges from 80% to 95%, with associated morbidity and mortality rates in larger series ranging from 6.5% to 8.7% and 0% to 1.3%, respectively. Intraoperative ERCP, facilitated by the placement of a transcystic wire through the papilla, has the advantage of 1-step therapy and confirmation of duct clearance. However, availability and appropriate expertise limit its usefulness. Placement of a transcystic ureteral catheter positioned in the duodenum, as described by Fitzgibbons and Colleagues, 20 can be performed at the time of laparoscopic cholecystectomy to facilitate postoperative ERCP and sphincterotomy. Other Surgical Techniques A number of surgical options, including several techniques for laparoscopic CBDE, have been described for the treatment of CBD stones discovered at the time of cholecystectomy. Before these options are considered, initial attempts at simple duct irrigation after glucagon administration are reasonable because this approach may clear stones without need for further manipulation. If duct irrigation is unsuccessful or cannot be performed, the most applicable laparoscopic procedure would be transcystic exploration, which generally involves dilation of the cystic duct. 19 This transcystic approach can also be used to achieve other options (eg, ductal irrigation, biliary endoscopy, stone retrieval using a fluoroscopically guided wire basket, ampullary balloon dilatation, antegrade sphincterotomy, or lithotripsy). Stone retrieval using a transcystic wire basket is applicable in 80% to 90% of patients with CBD stones. 19 Contraindications to this technique include stones greater than 9 mm in diameter, a large number of stones, and stones present in the proximal ductal system (which is inaccessible with this technique). Reported complications are relatively uncommon, occurring in 5% to 10% of cases, and can include cystic duct avulsion, bile duct perforation, retained stones, and pancreatitis. 19 Most of these conditions can be detected at the time of operation and with completion cholangiography. Fluoroscopic wire-basket retrieval of stones has the advantage of not requiring cystic duct dilation. 19 It is most successful when CBD stones are small. However, it requires fluoroscopy, has a lower overall success rate, and carries a risk of stone impaction into the nondilated cystic duct. Balloon dilation of the ampulla is particularly useful when there are small residual stones (or debris that does not clear with irrigation) and when a choledochoscope cannot be inserted into the cystic duct. 19 This procedure carries a risk of postoperative hyperamylasemia and pancreatitis. When the CBD is dilated, laparoscopic choledochotomy is an alternative technique to treat patients with single or multiple stones or if proximal common hepatic duct stones are present. 19 Direct access to the CBD is obtained, which allows for use of larger choledochoscopes and wire baskets. Bidirectional duct clearance can be performed, and a T-tube can also be placed for decompression, postoperative cholangiography, and a potential access site for postoperative retrieval of retained stones. This technique is not commonly used because it requires exposure of the CBD and advanced 8 Hospital Physician Board Review Manual

9 Laparoscopic cholecystectomy Cholangiography Normal Abnormal Complete procedure Duct exploration Complete procedure, postoperative ERCP Laparoscopic CBDE Open CBDE Choledochotomy, balloon, basket, lithotripsy, choledochoscopy, reverse papillotomy Transcystic, balloon, basket, lithotripsy, choledochoscopy T-tube, complete procedure T-tube, complete procedure Repeat cholangiography Normal Abnormal Complete procedure Options: choledochotomy, open CBDE, other transcystic, ampullary dilation, endoscopicassisted sphincterotomy Complete procedure, postoperative ERCP Figure 4. Algorithm for management of choledocholithiasis discovered at cholecystectomy. CBDE = common bile duct exploration; ERCP = endoscopic retrograde cholangiopancreatography. Adapted with permission from Ricardo AE, MacFayden BV Jr: Laparoscopic surgery of the biliary tree. Journal of Hepatobiliary and Pancreatic Surgery 1996;3: surgical skills, such as suturing to close the choledochotomy site and using a choledochoscope, dilators, and stone extractors. In experienced hands, this technique is generally favored when the CBD is greater than 8 mm in diameter, when stones are greater than 6 mm in diameter, and when the surrounding inflammation is minimal to mild. Less commonly used laparoscopic techniques include antegrade transcystic sphincterotomy and transcystic mechanical or electrohydraulic lithotripsy. Open Common Bile Duct Exploration Open CBDE remains a safe, successful, and viable alternative for the treatment of CBD stones. Reported experience shows that open CBDE can be performed with 0% mortality in patients younger than 60 years. Unfortunately, with the advent of laparoscopic cholecystectomy, surgical residency training in these techniques has become limited. An open approach allows for direct palpation and manipulation of the duct as well as an opportunity to perform biliary drainage (eg, choledochoduodenostomy). Currently, an open procedure is most often performed when open cholecystectomy is necessary or when laparoscopic CBDE fails in situations where postoperative endoscopy may be less successful (eg, with stones > 10 mm in diameter, lack of endoscopic access, associated biliary stricture, or impacted distal stones). An algorithm for management of CBD stones found at surgery is presented in Figure 4. Nonoperative Techniques Other, nonoperative techniques for the management of CBD stones include percutaneous transhepatic stone removal, which is generally performed when endoscopic access is not feasible. Successful stone extraction has been reported in more than 90% of cases; however, the procedure is associated with comparatively increased rates of morbidity and mortality. 17 Because spontaneous passage of CBD stones to the duodenum may occur, General Surgery Volume 6, Part 3 9

10 Predicted severe Urgent ERCP LC or laparotomy Biliary pancreatitis No stones present Evaluate & treat Low probability CBDS Same Admit LC Intraoperative cholangiogram LTCE LCDE OE Predicted mild Stones present High probability CBDS Preoperative ERCP Same Admit LC Postoperative ERCP Figure 5. Simplified algorithmic approach for the management of patients with acute biliary pancreatitis. The dashed line represents an acceptable alternative strategy. CBDS = common bile duct surgery; ERCP = endoscopic retrograde cholangiopancreatography; LC = laparoscopic cholecystectomy; LCDE = laparoscopic choledochotomy; LTCE = laparoscopic transcystic common bile duct exploration; OE = open choledochotomy. Adapted with permission from Schwesinger WH, Sirinek KR, Strodel WE 3rd: Laparoscopic cholecystectomy for biliary tract emergencies: state of the art. World J Surg 1999;23:338. observation alone with expectant management is an option that has been recommended by some authors in select cases. However, there are risks in leaving CBD stones in place, and the general consensus favors the removal of most CBD stones. In the rare instances where standard extraction techniques fail in patients who are not candidates for surgery, alternative options include ESWL, direct contact lithotripsy, or prolonged biliary stenting. GALLSTONE PANCREATITIS More than 50% of cases of acute pancreatitis in the United States are associated with gallstones. Most patients experience a self-limited clinical course; however, approximately 25% of patients develop more severe, life-threatening pancreatitis, with a 10% mortality rate. 21 An algorithm for management of biliary pancreatitis, as recommended by Schwesinger et al, 22 is outlined in Figure 5. Timing of cholecystectomy has little effect on outcomes in mild pancreatitis. In these cases, the procedure is safely performed after acute signs and symptoms have resolved. Because the recurrence of pancreatitis is common and because gallbladder-related complications can occur if the gallbladder is left in situ after endoscopic sphincterotomy, most patients with mild and/or rapidly resolving pancreatitis generally are best treated with same-admission cholecystectomy. In contrast, early surgery in patients with severe pancreatitis is associated with a significant increase in morbidity and mortality. 22 Therefore, a focus of recent research has been to determine which patients may benefit from early endoscopic intervention with ERCP. Determining the severity of acute pancreatitis can help determine the need for intensive care management, assess prognosis, and may prompt endoscopic intervention. Severity can be assessed by use of Ranson s criteria, Apache II scoring, development of organ system failure, and findings on CT. Four randomized control trials have compared conventional conservative treatment with urgent ERCP (within 24 to 72 hours of admission) in patients with acute biliary pancreatitis. ERCP was successfully performed in 80% to 96% of cases. A compilation of these findings is outlined in Table 4, with cases categorized as mild or severe. Although differences exist in study design and definitions of disease severity, the overall findings suggest that some reductions in morbidity and mortality result from early endoscopic intervention in patients with severe acute biliary pancreatitis (as predicted by prognostic scoring systems), biliary duct obstruction, or select patients who are not candidates for cholecystectomy because of associated medical conditions. BOARD REVIEW QUESTIONS Choose the single best answer for each question. 1. Patient 1 is a 37-year-old woman who is admitted with acute pancreatitis. Serum bilirubin, aspartate aminotransferase (AST), and alanine aminotransferase (ALT) are slightly increased. An ultrasound shows cholelithiasis and a common bile duct that is 4 mm in diameter. During the next 36 hours, patient 1 s symptoms resolve and laboratory data normalize. What is the most appropriate management course for patient 1? 10 Hospital Physician Board Review Manual

11 Table 4. Treatment of Acute Biliary Pancreatitis: Early ERCP/ERS versus Conservative Management Randomized Patients, n Morbidity, n (%) Mortality, n (%) Clinical Conservative Conservative Conservative Trial Treatment ERCP/ERS Treatment ERCP/ERS Treatment ERCP/ERS United Kingdom Mild (12%) 114 (12%)* 0 ( 0 ( Severe (61%) 116 (24%)* 5 (18%) 1 (4%)* Total (34%) 110 (17%)* 5 (8%)1 1 (2%) Hong Kong Mild (17%) 116 (18%)* 0( 0 ( Severe (54%) 114 (13%)* 5 (18%) 1 (3%)* Total (33%) 110 (16%)* 5 (8%) 1 (2%) Poland Mild (25%) 113 (9%)* 4 (5%) 1 (1%)* Severe (74%) 117 (41%)* 9 (33%) 3 (7%)* Total (38%) 130 (17%)* 13 (13%) 4 (2%)* Germany (51%) 158 (46%)* 7 (6%) 14 (11%) TOTAL (41%) 108 (25%)* 30 (9%)1 20 (5%) ERCP/ERS = endoscopic retrograde cholangiopancreatography/endoscopic retrograde sphincterotomy. *Statistically significant (P < 0.05). Nonbiliary pancreatitis excluded from analysis. Should be interpreted with caution because of major differences in study designs and populations (ie, this is not a true meta-analysis). Adapted with permission from Frakes JJ: Acute biliary pancreatitis: when is ERCP needed? Clinical Update, ASGE 1999;7:3. A) Discharge and continue clinical observation B) Proceed with laparoscopic cholecystectomy and cholangiography C) Perform endoscopic retrograde cholangiopancreatography (ERCP) D) Discharge and schedule elective cholecystectomy in 6 to 8 weeks 2. Patient 2 is a 54-year-old woman who presents with progressive jaundice. Six months ago, she underwent a difficult laparoscopic cholecystectomy for acute cholecystitis. ERCP now shows a 1-cm long stricture at the mid-common bile duct, with overlying metallic clips. The proximal biliary tree is dilated. What is the most appropriate way to proceed? A) Attempt balloon dilation of the stricture and internal stent placement B) Proceed with hepaticojejunostomy C) Proceed with choledochoduodenostomy D) Obtain transhepatic external biliary drainage 3. Patient 3 is a 24-year-old woman who is 8 weeks pregnant. She presents with an acute episode of right upper quadrant abdominal pain, which lasts for 2 hours. Ultrasound reveals cholelithiasis without evidence for acute cholecystitis. What would you recommend? A) Endoscopic sphincterotomy B) Percutaneous cholecystostomy C) Laparoscopic cholecystectomy D) Nonoperative management 4. Patient 4 is a 45-year-old man undergoing cholecystectomy for chronic cholecystitis. Intraoperative cholangiography shows a sharp cut-off of the midcommon bile duct with filling of the distal duct only. There is free flow to the duodenum, and no stones are seen. What should be done next? A) Clip the ductotomy site and complete the cholecystectomy B) Surgical exploration and evaluation for duct injury C) Place a closed-suction drain and monitor postoperatively for bile leak D) Plan for postoperative ERCP General Surgery Volume 6, Part 3 11

12 DETAILED ANSWERS 1. (B) Proceed with laparoscopic cholecystectomy and cholangiography. Patients with mild-to-moderate gallstone pancreatitis that has clinically resolved have likely passed a common bile duct stone. Routine ERCP is therefore of low yield in this group of patients. Because of the high risk of recurrent symptoms, optimal treatment in most cases is to proceed with same-admission cholecystectomy. 2. (A) Attempt balloon dilation of the stricture and internal stent placement. Short, partial strictures of the bile duct associated with iatrogenic injury may respond to endoscopic therapy with dilation and prolonged stenting. Internal stenting results in less morbidity than external transhepatic drainage. If the stricture does not respond to endoscopic treatment, the best surgical option for repair is hepaticojejunostomy. 3. (D) Nonoperative management. Although pregnant patients with biliary colic have a 30% to 40% risk of recurrent symptomatic cholelithiasis, initial attempts at nonoperative management are warranted. Surgery is best delayed until the second trimester to reduce the risk of fetal demise or induction of labor. The role of percutaneous cholecystostomy is limited to select patients with acute cholecystitis. 4. (B) Surgical exploration and evaluation for duct injury. This cholangiogram finding is consistent with a major iatrogenic ductal injury. The best long-term outcome is achieved by early recognition and appropriate repair. A complete duct transection is best treated with Roux-en Y choledochojejunostomy. REFERENCES 1. Gallstones and laparoscopic cholecystectomy. NIH Consens Statement 1992;10: Strasberg SM: The pathogenesis of cholesterol gallstones: a review. J Gastrointest Surg 1998;2: Strasberg SM, Clavien PA: Cholecystolithiasis: lithotherapy for the 1990s. Hepatology 1992;16: Patino JF, Quintero GA: Asymptomatic cholelithiasis revisited. World J Surg 1998;22: Gholson CF, Sittig K, McDonald JC: Recent advances in the management of gallstones. Am J Med Sci 1994;307: Perissat J: Laparoscopic cholecystectomy, a treatment for gallstones: from idea to reality. World J Surg 1999;23: Bongard F, Dubecz S, Klein S: Complications of therapeutic laparoscopy. Curr Probl Surg 1994;31: Russell JC, Walsh SJ, Mattie AS, Lynch JT: Bile duct injuries, A statewide experience. Connecticut Laparoscopic Cholecystectomy Registry. Arch Surg 1996; 131: Phillips EH: Routine versus selective intraoperative cholangiography. Am J Surg 1993;165: Strasberg SM, Hertl M, Soper NJ: An analysis of the problem of biliary injury during laparoscopic cholecystectomy. J Am Coll Surg 1995;180: Hamy A, Visset J, Likholatnikov D, et al: Percutaneous cholecystostomy for acute cholecystitis in critically ill patients. Surgery 1997;121: Gouldman JW, Sticca RP, Rippon MB, McAlhany JC Jr: Laparoscopic cholecystectomy in pregnancy. Am Surg 1998;64: Hermann RE: The spectrum of biliary stone disease. Am J Surg 1989;158: Phillips EH, Liberman M, Carroll BJ, et al: Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary? Arch Surg 1995;130: Franceschi D, Brandt C, Margolin D, et al: The management of common bile duct stones in patients undergoing laparoscopic cholecystectomy. Am Surg 1993;59: Varghese JC, Liddell RP, Farrell MA, et al: The diagnostic accuracy of magnetic resonance cholangiopancreatography and ultrasound compared with direct cholangiography in the detection of choledocholithiasis. Clin Radiol 1999;54: Rosenthal RJ, Rossi RL, Martin RF: Options and strategies for the management of choledocholithiasis. World J Surg 1998;22: Traverso LW: A cost-effective approach to the treatment of common bile duct stones with surgical versus endoscopic techniques. In Bile Ducts and Bile Duct Stones. Berci G, Cuschieri A, eds. Philadelphia: WB Saunders, 1997: Crawford DL, Phillips EH: Laparoscopic common bile duct exploration. World J Surg 1999;23: Fitzgibbons RJ Jr, Ryberg AA, Ulualp KM, et al: An alternative technique for treatment of choledocholithiasis found at laparoscopic cholecystectomy. Arch Surg 1995; 130: Frakes JT: Acute biliary pancreatitis: when is ERCP needed? Clinical Update, ASGE 1999;7: Schwesinger WH, Sirinek KR, Strodel WE 3rd: Laparoscopic cholecystectomy for biliary tract emergencies: state of the art. World J Surg 1999;23: Copyright 2001 by Turner White Communications Inc., Wayne, PA. All rights reserved. 12 Hospital Physician Board Review Manual