Title: A CASE PRESENTATION, MANAGEMENT, DISCUSSION AND SHARING OF INFORMATION ON OBSTRUCTIVE JAUNDICE SECONDARY TO CHOLEDOCHOLITHIASIS
1A 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
4HISTORY 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
5HISTORY 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
6Past Medical History
- No hypertension
- No diabetes
- No PTB
- No previous hospitalization
- No allergies to foods and drugs
7Family History
8Personal and Social History
- Unremarkable
- Occasional alcoholic beverage drinker
9Physical 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
10Physical 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
11Physical Examination
- Heart
- normal rate, regular rhythm, no murmur
- Abdomen
- Flat, NABS, soft, with Direct Tenderness
RUQ, no organomegaly.
12Physical Examination
- Extremities
- Full and equal pulses, no deformities, no
cyanosis - DRE
- -light colored stool
13Salient 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
14NON OBSTRUCTIVE
OBSTRUCTIVE
EXTRAHEPATIC
INTRAHEPATIC
COMPRESSION OF BILIARY TRACTS
INTRADUCTAL
HEMOLYSIS
HEPATOCELLULAR
15OBSTRUCTIVE
EXTRAHEPATIC
INTRAHEPATIC
GB/CBD stones
Pancreatic Ca
Primary Biliary Cirrhosis Sclerosing Cholangitis
Pattern Recognition (90-95) RUQ pain
Clinical Jaundice CBD dilatation
16Initial Impression
Diagnosis Certainty
Primary Diagnosis Obstructive Jaundice prob secondary to Choledocholithiasis Cholecystolithiasis 95
Secondary Diagnosis Jaundice prob secondary to Chronic Liver Disease 5
17Para clinical Diagnostic Procedure
- Do I need to perform a Para clinical diagnostic
procedure? - No
18Pretreatment 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
19Pre Treatment Diagnosis
Obstructive Jaundice prob secondary
to Choledocholithiasis Cholecystolithiasis
20GOALS OF TREATMENT
- Resolution of obstruction
- Prevention of complication
21Treatment 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
22Management
- OPEN CBDE
- CHOLECYSTECTOMY, IOC
23Preoperative Preparation
- Informed consent
- Provide psychosocial support
- Optimize patients condition
- NPO for 6 hours
- Preparation of OR materials
24Operative 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
25Operative 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
26Operative Technique
- T-tube inserted and anchored
- Hemostasis
- Correct sponge and instruments count
- Layer by layer closure
- DSD
27Operative 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.
28Postoperative Diagnosis
- Obstructive Jaundice Secondary to
Choledocholithiasis - Cholelithiasis
- Operation Done
- Open Cholecystectomy, Common Bile Duct
Exploration, Intraoperative Cholangiography,
T-Tube Choledochostomy
29Postoperative 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.
-
30Final Diagnosis
- Obstructive Jaundice Secondary to
Choledocholithiasis - Cholelithiasis
- S/P Open Cholecystectomy, Common Bile Duct
Exploration, Intraoperative Cholangiography,
T-Tube Choledochostomy
31COURSE IN THE WARD
- 1st Hospital Day
- NPO
- Adequate Antibiotic
- Adequate Analgesia
- DWC
32COURSE IN THE WARD
- 2nd-3rd Hospital Day
- GL- Soft diet
- Adequate Antibiotic
- Adequate Analgesia
- DWC
33COURSE IN THE WARD
- 4th Hospital Day
- DAT
- Adequate Antibiotic
- Adequate Analgesia
- DWC
34COURSE IN THE WARD
- 5th Hospital Day
- Patient discharged
35PREVENTION 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
36SHARING OF INFORMATI0N
37Common 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.
38Overview 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
39Completion 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
41Questions
- 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
42Questions
- 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.
43Questions
- 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
44Questions
- (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.
45Questions
- 4 (MCR)
- The following are drainage procedure after
open/laparoscopic CBDE. - 1. Sphincteroplasty
- 2. Choledochojeunostomy
- 3. Choledochoduodenostomy
- 4. Choledochotomy
46Questions
- 5 (MCR)
- Correct statement about biliary scintigraphy
using technetium 99m- labeled derivatives of
iminoacetic acid (HIDA) include -
47Questions
- 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
48Journal 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
49Objective
- 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.
50Design
51Patients
- Forty consecutive patients undergoing elective
minilap cholecystectomy and CBD exploration for
gallstones with CBD stones (proved preoperatively
on ultrasonography) were studied prospectively.
52Intervention
- Patients were randomly divided in two groups
Group A underwent primary closure of CBD, group B
had T-tube drainage after CBD exploration.
53Main outcome measures
- The duration of hospital stay, mortalities,
morbidities and outcome.
54Results
DURATION OF SURGERY (plt0.001)
GRP A 87.75 min.
GRP B 116.65 min.
55Results
DURATION OF ANALGESIA (plt0.001)
GRP A 3.35 days
GRP B 5.3 days
56Results
DURATION OF ANALGESIA (plt0.001)
GRP A 3.35 days
GRP B 5.3 days
57Results
Morbidity
GRP A 5
GRP B 40
58Results
Mortality
GRP A 0
GRP B 5
59Results
Length of Hospital Stay
GRP A 4.4 days
GRP B 15.4 days
60Conclusion
- The use of T-tube following routine
choledochotomy is unnecessary and increases
postoperative morbidity and mortality.
61Clinical Question
- In cases of obstructive jaundice secondary to
choledocholithiasis, is mandatory t- tube
choledochostomy necessary?
62Tentative Answer
- No
- mandatory t tube choledochosyomy is not necessary
for cases of obstructive jaundice secondary to
choledocholithiasis.
63 64Are the results of the study valid?
- Primary Guides
- 1. Was the assignment of patients to treatment
randomized? - Yes.
65Are 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.
66Are the results of the study valid?
- Secondary Guides
- Were patients, their clinicians, and study
personnel "blind" to treatment? - No.
67Are the results of the study valid?
- Secondary Guides
-
- 5. Aside from the experimental intervention, were
the groups treated equally? - Yes.
68Are the results of the study valid?
- Secondary Guides
-
- 4. Were the groups similar at the start of the
trial? - Yes.
69Are the results of the study valid?
- Secondary Guides
-
- 4. Were the groups similar at the start of the
trial? - Yes.
70Conclusion
- 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.
71References
- 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.
72- EVIDENCE-BASED CLINICAL PRACTICE GUIDELINES ON
COMMON BILE DUCT STONES FOR SURGICAL PROCEDURES - UPDATE 2004
73COMMON 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.
77- 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.
78INTRAHEPATIC 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.
80- 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.
81CHOLANGITIS
- 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).
83RETAINED 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.
84