A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS

1
A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND
SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE
SECONDARY TO CHOLEDOCHOLITHIASIS

• BY
• Jonathan R. Malabanan, M.D.
• Ospital ng Maynila Medical Center
• Department of Surgery

2

• General Data
• A.M.
• 35 years- old
• Female
• Binondo, Manila

3

• Chief Complaint
• Yellowish discoloration of the eyes

4
HISTORY OF PRESENT ILLNESS

• One month PTC
• RUQ pain, colicky, moderate to severe,
  radiating to R scapular area
• no fever, no yellowish discoloration of
  skin and sclerae
• no consult, no meds

5
HISTORY OF PRESENT ILLNESS

• One week PTC persistence of colicky right
  upper quadrant pain
• yellowish
  discoloration of skin and sclerae
• () light colored stool
• () consult, HBT-
  UTZ done Choledocholithiasis,
  Cholecystolithiais
• Advised OR, and was scheduled for
  operation

6
Past Medical History

• No hypertension
• No diabetes
• No PTB
• No previous hospitalization
• No allergies to foods and drugs

7
Family History

• unremarkable

8
Personal and Social History

• Unremarkable
• Occasional alcoholic beverage drinker

9
Physical Examination

• General Survey
• Conscious, coherent, not in respiratory distress
• Vital Signs
• BP 110/ 60 mmHg CR 81 bpm
• RR 20 cpm Temp 37 degrees Celsius

10
Physical Examination

• Skin yellowish coloration of skin
• HEENT
• - Pink palpebral conjuctivae, icteric sclerae, no
  CLAD, no TPC, no NAD, supple neck.
• Chest
• Symmetrical chest expansion, no retractions,
• CBS

11
Physical Examination

• Heart
• normal rate, regular rhythm, no murmur
• Abdomen
• Flat, NABS, soft, with Direct Tenderness
  RUQ, no organomegaly.

12
Physical Examination

• Extremities
• Full and equal pulses, no deformities, no
  cyanosis
• DRE
• -light colored stool

13
Salient Features

•  
• 1. 35/Female
• 2. RUQ pain
• 3. Yellowish discoloration of the eyes, skin
• 4. Light colored stool
• 5. UTZ result of Hepatobiliary Tree dilated
  CBD, normal liver, portal vein and tributaries
  are unremarkable, intrahepatic ducts not dilated,
  with an intraluminal echogenic focus exibiting
  acoustic shadowing

14

• JAUNDICE

NON OBSTRUCTIVE
OBSTRUCTIVE
EXTRAHEPATIC
INTRAHEPATIC
COMPRESSION OF BILIARY TRACTS
INTRADUCTAL
HEMOLYSIS
HEPATOCELLULAR
15
OBSTRUCTIVE
EXTRAHEPATIC
INTRAHEPATIC
GB/CBD stones
Pancreatic Ca
Primary Biliary Cirrhosis Sclerosing Cholangitis
Pattern Recognition (90-95) RUQ pain
Clinical Jaundice CBD dilatation
16
Initial Impression
Diagnosis Certainty
Primary Diagnosis Obstructive Jaundice prob secondary to Choledocholithiasis Cholecystolithiasis 95
Secondary Diagnosis Jaundice prob secondary to Chronic Liver Disease 5
17
Para clinical Diagnostic Procedure

• Do I need to perform a Para clinical diagnostic
  procedure?
• No

18
Pretreatment Diagosis
Diagnosis Certainty
Primary Diagnosis Obstructive Jaundice prob secondary to Choledocholithiasis Cholecystolithiasis 95 SURGICAL Medical
Secondary Diagnosis Jaundice prob secondary to Chronic Liver Disease 05 MEDICAL
19
Pre Treatment Diagnosis
Obstructive Jaundice prob secondary
to Choledocholithiasis Cholecystolithiasis
20
GOALS OF TREATMENT

• Resolution of obstruction
• Prevention of complication

21
Treatment Options
Treatment Benefit Risk Cost Availability
ERCP -able to achieve primary treatment objective SR81-98 CBD Clearance -bleeding -perforation -pancreatitis 12-15,000 Not available
Open surgery -able to achieve primary treatment objective SR90-100 CBD Clearance -complications of anesthesia -bleeding -iatrogenic injury to biliary ducts 20-30,000 pesos in private hospitals free to charity pxs at OM available
Laparo-scopic surgery -able to achieve primary treatment objective SR85-100 CBD Clearance -complications of anesthesia -bleeding -iatrogenic injury to biliary ducts -trocar and needle insufflation injuries 40-60,000 pesos in private hospitals Not available
22
Management

• OPEN CBDE
• CHOLECYSTECTOMY, IOC

23
Preoperative Preparation

• Informed consent
• Provide psychosocial support
• Optimize patients condition
• NPO for 6 hours
• Preparation of OR materials

24
Operative technique

• Patient supine under GA
• Asepsis/Anti-sepsis
• Sterile drapes placed
• Right paramedian incision carried down from skin
  to subcutaneous tissue, fascia and peritoneum
  entered
• Intraoperative findings noted

25
Operative Technique

• Cystic artery identified, ligated and cut
• Cystic duct identified, isolated and tagged
• Gallbladder removed. Intraoperative findings
  noted.
• French 5 feeding tube inserted into the cystic
  duct, IOC done, results noted
• CBD opened logitudinally and explored

26
Operative Technique

• T-tube inserted and anchored
• Hemostasis
• Correct sponge and instruments count
• Layer by layer closure
• DSD

27
Operative Findings

• Intraoperative findings noted
• GB is distended with thickened walls measuring
  10x4cm on opening up, it contained multiple
  stone measuring 0.2-0.3cm, cystic duct measures
  0.5cm in diameter CBD measured 12mm in diameter
  on IOC, there was a filling defect on the distal
  CBD, there was visualization of both intrahepatic
  ducts. On CBDE, 8mm primary stone was noted at
  the distal common bile duct. Pancreas was normal.
  Liver was noted to be cirrhotic.

28
Postoperative Diagnosis

• Obstructive Jaundice Secondary to
  Choledocholithiasis
• Cholelithiasis
• Operation Done
• Open Cholecystectomy, Common Bile Duct
  Exploration, Intraoperative Cholangiography,
  T-Tube Choledochostomy

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Postoperative Management

• Adequate analgesia
• Monitoring of VS and hydration.
• DAT
• Adequate monitoring complications
• Patient was discharged on the 5th post operative
  day
• Follow up after a week.

30
Final Diagnosis

• Obstructive Jaundice Secondary to
  Choledocholithiasis
• Cholelithiasis
• S/P Open Cholecystectomy, Common Bile Duct
  Exploration, Intraoperative Cholangiography,
  T-Tube Choledochostomy

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COURSE IN THE WARD

• 1st Hospital Day
• NPO
• Adequate Antibiotic
• Adequate Analgesia
• DWC

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COURSE IN THE WARD

• 2nd-3rd Hospital Day
• GL- Soft diet
• Adequate Antibiotic
• Adequate Analgesia
• DWC

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COURSE IN THE WARD

• 4th Hospital Day
• DAT
• Adequate Antibiotic
• Adequate Analgesia
• DWC

34
COURSE IN THE WARD

• 5th Hospital Day
• Patient discharged

35
PREVENTION AND HEALTH PROMOTION

• Advise given to patient regarding
• Possible complications
• Proper wound care
• OPD follow up after 7 days for removal of sutures
• Anticipate complications
• Avoid Recurrence
• Avoid infection

36
SHARING OF INFORMATI0N
37
Common Bile Duct Stones

• 10 of patients who present for Cholecystectomy
• definitive treatment is cholecystectomy and
  ductal clearance either through open CBDE, Lap
  CBDE, ERCP.
• Manuevers include administration of glucagon and
  flushing of ductal system,dilatation of the
  distal CBD, balloon catheter, basket extraction.

38
Overview to Patient Management

• CBD stones can be discovered preoperatively,
  intraop, post-op.
• Treatment options
• ERCP/-S
• Lap CBDE
• Lap Chole ERCP
• Open CBDE
• almost same success rate

39
Completion CBDE     

• T tube placement
• decompression of the duct, incase of residual
  obstruction
• access for ductal imaging postop
• access for removal of stone
• left as early as 4 days up to 6 weeks
• complicatios bile leaks, peritonitis

40

• Post Cholecystectomy CBDE Problems
• Early Problems
• bile duct injury laceration, cystic duct stump
  leak, liver bed leak
• bile duct obstruction retained stone
• biliary pancreatitis
• Late Problems
• stricture
• postcholecystectomy syndrome
• GERD

41
Questions

• 1 (MCQ) Which of the following is the main
  chemical component of pigment stones? A.
  CholesterolB. Calcium bilirubinate C. Calcium
  carbonateD. Calcium phosphate
• E Calcium oxalate

42
Questions

• 2 (MCQ) What is the most commonly isolated
  bacteria in the common duct of patient with
  primary stone?
• A. Escherichia coli
• B. Pseudomonas aeruginosa
• C. Klebsiella sp.
• D. Salmonella typhii
• E. Corynebacterium sp.

43
Questions

• 3 (MCQ) Which of the following is the best
  indication for preoperative ERCP in patients with
  gallstones?
• A. Gallstone pancreatitis
• B. Obstructive jaundice
• C. History of jaundice
• D. Increased alkaline phosphatase to twice
  normal
• E. 1.6 cm common bile duct dilatation

44
Questions

• (MCR)
• Direction Write
• A if 1, 2, and 3 are valid statements.
• B if only 1 and 3 are valid statements.
• C if only 2 and 4 are valid statements.
• D if only 4 is a valid statement.
• E if all are valid statements.

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Questions

• 4 (MCR)
• The following are drainage procedure after
  open/laparoscopic CBDE.
• 1. Sphincteroplasty
• 2. Choledochojeunostomy
• 3. Choledochoduodenostomy
• 4. Choledochotomy

46
Questions

• 5 (MCR)
• Correct statement about biliary scintigraphy
  using technetium 99m- labeled derivatives of
  iminoacetic acid (HIDA) include

47
Questions

• 5 (MCR)
• 1. Nonvisualization of GB is strong evidence of
  cystic duct obstruction.
• 2. The isotope is cleared by Kupffers cells
• 3. The GB in a fasting subject is normally
  visualized within 60 minutes of the dye injection
• 4. The scan is the preferred initial step in
  identifying common duct stones

48
Journal Appraisal

• Evaluation of primary duct closure vs T-tube
  drainage following choledochotomy
• Marwah Sanjay, Singh Ishwar, Godara Rajesh, Sen
  Jyotsana, Marwah Nisha, Karwasra RKDepartments
  of Surgery, Postgraduate Institute of Medical
  Sciences, Rohtak, Haryana, IndiaYear 2004   
  Volume 23    Issue 6    Page 227-228

49
Objective

• To assess the benefits and harms of primary
  closure versus routine T-tube drainage in open
  common bile duct exploration for common bile duct
  stones.

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Design

• Randomized Control Trial

51
Patients

• Forty consecutive patients undergoing elective
  minilap cholecystectomy and CBD exploration for
  gallstones with CBD stones (proved preoperatively
  on ultrasonography) were studied prospectively.

52
Intervention

• Patients were randomly divided in two groups
  Group A underwent primary closure of CBD, group B
  had T-tube drainage after CBD exploration.

53
Main outcome measures

• The duration of hospital stay, mortalities,
  morbidities and outcome.

54
Results
DURATION OF SURGERY (plt0.001)
GRP A 87.75 min.
GRP B 116.65 min.
55
Results
DURATION OF ANALGESIA (plt0.001)
GRP A 3.35 days
GRP B 5.3 days
56
Results
DURATION OF ANALGESIA (plt0.001)
GRP A 3.35 days
GRP B 5.3 days
57
Results
Morbidity
GRP A 5
GRP B 40
58
Results
Mortality
GRP A 0
GRP B 5
59
Results
Length of Hospital Stay
GRP A 4.4 days
GRP B 15.4 days
60
Conclusion

• The use of T-tube following routine
  choledochotomy is unnecessary and increases
  postoperative morbidity and mortality.

61
Clinical Question

• In cases of obstructive jaundice secondary to
  choledocholithiasis, is mandatory t- tube
  choledochostomy necessary?

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Tentative Answer

• No
• mandatory t tube choledochosyomy is not necessary
  for cases of obstructive jaundice secondary to
  choledocholithiasis.

63

• Appraisal Guide

64
Are the results of the study valid?

• Primary Guides
• 1. Was the assignment of patients to treatment
  randomized?
• Yes.

65
Are the results of the study valid?

• Primary Guides
• 2. Were all patients who entered the trial
  properly accounted for and attributed at its
  conclusion?
• Yes.

66
Are the results of the study valid?

• Secondary Guides
• Were patients, their clinicians, and study
  personnel "blind" to treatment?
• No.

67
Are the results of the study valid?

• Secondary Guides
• 5. Aside from the experimental intervention, were
  the groups treated equally?
• Yes.

68
Are the results of the study valid?

• Secondary Guides
• 4. Were the groups similar at the start of the
  trial?
• Yes.

69
Are the results of the study valid?

• Secondary Guides
• 4. Were the groups similar at the start of the
  trial?
• Yes.

70
Conclusion

• The use of T-tube following routine
  choledochotomy is unnecessary and increases
  postoperative morbidity and mortality.
• Primary closure of CBD is more safe and
  physiological and the procedure of choice
  following routine choledochotomy.

71
References

• Schwartz et. al Principles of Surgery.8th ed.
  Chapter 6.
• Marwah S, Singh I,Godara R, Sen J,MarwahN,
  Karwasra RK. Evaluation of primary duct closure
  vs T-tube drainage following choledochotomy.
• Indian Journal of Gastroenterology
  200423(6)2278.
• Wright BE, Freeman ML, Cummings JK et. al.
  Current Management of Common Bile Duct Stones.
  Surgery. 132729-735, 2002.

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• EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON
  COMMON BILE DUCT STONES FOR SURGICAL PROCEDURES
• UPDATE 2004

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COMMON BILE DUCT STONES

• 1. What is the recommended ancillary procedure in
  a patient with suspected
• common duct stone to confirm its diagnosis?

74

• Magnetic resonance cholangiography is the
  recommended procedure for patients with suspected
  common bile duct stones to confirm the diagnosis.

75

• 2. What is the recommended treatment for patients
  with CBD stones without
• cholangitis?
• The recommended treatment for patient with CBD
  stones without cholangitis is
• surgical treatment.

76

• 3. Among the different treatment options for
  common bile duct stones, which
• procedure has the least recurrence?
• Choledochoduodenostomy has the least recurrence.

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• 4. What is the recommended treatment for patients
  with gall bladder stones after
• endoscopic common bile duct clearance?
• The recommended treatment for patients with gall
  bladder stones after endoscopic
• common bile duct clearance is surgery, to be
  performed within 24 to 48 hours after
• clearance.

78
INTRAHEPATIC STONES (HEPATOLITHIASIS)

• 1. What is the recommended diagnostic tool to
  confirm the presence of intrahepatic
• stones with or without strictures?

79

• Magnetic resonance cholangiography is the
  recommended diagnostic tool to confirm the
  presence of intrahepatic stones.

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• 2. What is the recommended treatment for
  intrahepatic stones with or without
• strictures?
• The recommended treatment include surgical
  management (hepatic resection) and
  cholangioscopic techniques, whether through a
  T-tube tract, a percutaneous transhepatic
  approach (PTBD/PTCS) or a transpapillary
  approach, singly or in combination.

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CHOLANGITIS

• 1. What is the antibiotic of choice for patients
  with cholangitis?
• The recommended antibiotics for the treatment of
  cholangitis are Ciprofloxacin 200mgs IV BID or
  Ceftazidime 1gm IV BID Ampicillin 500mgs IV QID
  Metronidazole 500mgs IV TID

82

• 2. What is the recommended treatment for patients
  with severe cholangitis?
• The recommended treatment for patients with
  severe cholangitis is non-operative biliary
  drainage (endoscopic).

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RETAINED COMMON BILE DUCT STONES

• 1. What is the recommended treatment for retained
  common bile duct stones?
• For patients who have had prior cholecystectomy
  and have a high probability of common bile duct
  stones, ERCP and sphincterotomy with DORMIA
  basket extraction is the preferred initial
  approach.

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• Thank you!