“More Than You Bargained For”
Dr Asif Khan
MRCP 2007
Case 1
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38 y/o female.
Rt upper quadrant pain and vomiting, deranged LFT’s
(obstructive picture) PMH includes
 ERCP
 Two stones 8 and 10mm identified but unable to
remove, stent was placed and sphincterotomy
performed.
Laparoscopic Cholecystectomy
Clinical Exam
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Afebrile, hemodynamically stable.
Scleral icterus.
Abdomen soft, mildly tender , negative Murphy’s sign.
No rebound tenderness/guarding, no masses appreciated.
Blood Results:
 WBC
4.6 x 109/L (4-10 109/L )
 AST
258
IU/L (14-54 ) ; ALT 352 IU/L (14-54)
 Billirubin 77 umol/L (3.4-20.5)
 Alkaline phosphatase 258 IU/L ( 42-121)
 INR 1.1
Investigations
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U/S – Dilated CBD (14mm) containing two stones, one
13 mm.
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ERCP attempted
Blocked stent , dilated CBD , two large stones >1cm in
size, small stones and sludge. Stent changed and surgical
intervention suggested as stones unretrievable via ERCP
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MRCP – planning – pre IR
Confirms ductal stones and dilated ducts
Prominent ducts especially those beyond the stones in
the right radicular duct system.
 Modified Burhenne PTC technique - feasible
Investigations
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MRCP; to assess interventional approach
Percutaneous Approach
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Right PTC: Access ducts beyond incarcerated stone -a prerequisite
Stone
Management
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PTC and cannulation guide wire technique
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Modified “ Burhenne” technique
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Over the wire Fogarty Balloon - push
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Stones were pushed into the duodenum and stent inserted.
CBD was cleared.
PTC: Right needle access to biliary ducts - fluoroscopy
Stone
Over the wire Fogarty Balloon 5 Fr
“ Burhenne” - push
Post Procedure
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Post interventional radiology,
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Patient made good recovery
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Discharged home no further episodes.
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LFT’s normal.
Case 2
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72 y/o female.
Admitted with RUQ pain , fever and jaundice.
Clinical picture of Cholangitis treated with IV antibiotics ,fluid
resuscitation and analgesia.
Recurrent admission for symptomatic choledocholithiasis and
repeated ERCP attempts
 ERCP 1-failed
 ERCP 2-failed
 ERCP 3-failed
Investigations
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US Abdomen –Multiple gall stones and CBD diameter 1.1 cm.
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MRCP - Gall stones and multiple ductal stones , dilated CBD.
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ERCP - Unable to remove stones and stent was inserted.
MRCP 2
Management
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Open cholecystectomy and CBD Exploration
performed.
 Findings: More than 12 big and small stones removed from
CBD. Normal anatomy.
 Duct clear on choledochoscopy.
T tube cholangiogram Day 7 post op
 Findings: Two retained stones in Rt duct system.
T tube cholangiogram
Management
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Percutaneous approach to stone clearance
Modified “Burhenne technique” – push.
T –tube track.
Duct cannulation per T tube track. Catheter –wire contrast
technique
Over the wire Fogarty Balloon stone pull - push to duodenum.
Pull
Push
External Drain After Modified Burhenne Technique
Management
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Overnight external drain
Check cholangiogram following morning.
 Findings: Duct clear. External drain removal
 LFT’S normal.
Discussion
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Last 30 years have seen major advances in the
management of gallstone disease, which in the U.S.
alone, costs over 6 billion dollars per annum to treat.
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In patients who have cholecystectomy for gallbladder
stones, approximately 10% to 18% also have common
bile duct (CBD) stones.
Gut 2008;57:1004–1021.doi:10.1136/gut.2007.121657
Pathogenesis
 CBD Stones
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Primary CBD stones
 Bilirubin is dominant component.
Secondary CBD Stones
 Descend from the gallbladder
 Cholesterol is dominant component.
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Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 page
Clinical Presentation
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Asymptomatic
Symptomatic
 Biliary colic with pale stools, dark-colored urine and pruritis.
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Cholangitis or gallstone pancreatitis.
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Acute obstructive cholangitis is a life-threatening complication
caused by an infection secondary to biliary obstruction.
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Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages
doi:10.1155/2009/840208
Diagnosis
Investigation
Sensitivity
Specificity
US
25-82%
56-100%
EUS
95 %
95-98 %
MRCP
95 %
97 %
CT
87 %
97 %
Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages
Management Options– CBD Stones
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Open cholecystectomy + CBD exploration.
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ERCP + Endoscopic Sphincterotomy (followed by
cholecystectomy – most frequently used).
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Laparoscopic cholecystectomy + Laparoscopic CBD
exploration – in specialized centers.
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Choledochoscopy at laparoscopy or percutaneous
choleydochoscopy or choleydochoscopy through T tube.
CBD stones
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ERCP has become a popular technique to clear CBD stones.
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Currently in the laparoscopic era studies have shown that
laparoscopic treatment of CBD stones is possible and is
potentially as effective as ERCP.
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This is most commonly done by a transcystic approach, though
evidence of success in large volume cohorts with a more
technically demanding laparoscopic Choledochotomy is
emerging .
(Fletcher 1994 ;Cuschieri 1996; Lezoche 1996)
ERCP
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Despite the fact that therapeutic ERCP is increasingly being
used to manage biliary tract diseases, the procedure remains
compounded by two persistent problems: failure of successful
biliary cannulation, and post ERCP-pancreatitis (PEP).
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PTC and guide-wire cannulation has been proposed as a
simple way to avoid PEP.
Lella F, Bagnolo F, Colombo E, Bonassi U. A simple way of avoiding
post- ERCP pancreatitis. Gastrointest Endosc 2004; 59: 830-834.
Bailey AA, Bourke MJ, Williams SJ, et al. A prospective randomized trial of cannulation technique
in ERCP: Effects on technical success and post-ERCP pancreatitis. Endoscopy 2008; 40: 296301.
Management – CBD Stones
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Burhenne technique
 Treatment of retained CBD stones found on T tube
cholangiography
 Technique modified by ERCP and sphincterotomy practice
 Percutaneous extraction or duodenal deposition under
fluoroscopic control. Catheter –wire – contrast - balloon
 Approach depends on ? +/- sphincterotomy
 Percutaneous sphincteroplasty - alternative
British Journal of SurgeryVolume 78 Issue 8, Pages 959 - 960
Management – CBD Stones
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Percutaneous therapy is the option before resorting to surgery.
Fluoroscopically-guided extraction of resident calculi through a
sinus tract T tube (Kher tube) is a well-established procedure.
If no T tube is in place, a transhepatic approach may be attempted.
“Rendez-vous”technique. Combined percutaneous IR and
endoscopic ERCPprocedure
Burhenne HJ. Percutaneous extraction of retained biliary tract stones: 661 patients. AJR1980
Rendez-vous guide-wire technique
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The PTC guide-wire technique seems to reduce the incidence
of post-ERCP pancreatitis in the elderly as compared to the
conventional contrast technique, but does not appear to
improve the primary success rate for biliary cannulation
during ERCP in this population.
Lazaraki G, Katsinelos P. Prevention of post- ERCP pancreatitis: an overview. Ann
Gastroenterol 2008; 21: 27-38.
Adjuvant Techniques with ERCP
+ES
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Laparoscopic CBD exploration/Choleydochoscopy.
Mechanical lithotripsy
LASER lithotripsy
Electrohydraulic lithotripsy
ESWL
Chemical contact dissolution therapy
Take Home Message
CBD Stones associated with 10-18 % of patients
undergoing cholecystectomy.
 Advanced endoscopic & laparoscopic
techniques have revolutionized management.
 PTC and IR (guide wire cannulation) are still successful
techniques for retained stones.
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