From
StayCurrentMD
Choledocholithiasis: Diagnosis and management
With Dr. Jeff Ponsky
Part of
Choledocholithiasis 6 items
Chapter 1 of 10 · Fundamentals
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What the experts said
Patients with deep jaundice or cholangitis (jaundice, fever, right upper quadrant pain, sometimes sepsis) are potential candidates for emergency ERCP to relieve common bile duct obstruction
Patients with gallstone pancreatitis (jaundice, abdominal pain, and elevated pancreatic enzymes) are potential candidates for emergency ERCP
If a patient's pancreatitis improves the next day, there is no rush to do ERCP
ERCP is definitely overused
If a patient can go to the operating room and have an intraoperative cholangiogram and management of common bile duct stones in one episode, they may be better off than having a preoperative ERCP
The first step in management of suspected common bile duct stones is to get an intraoperative cholangiogram
Intraoperative cholangiogram should be done with fluoroscopy and not static X-rays
The transcystic route is amenable to small stones, usually in the distal duct
Glucagon can be used to relax the papilla of Vater to allow flushing or pushing tiny stones through
It is not difficult to do a laparoscopic common bile duct exploration
For laparoscopic CBD exploration, a small incision of perhaps 1 centimeter is made in the anterior surface of the common bile duct
A 12 or 14 French T-tube is typically used for CBD closure after exploration
The back wall of the T-tube is cut off and sliced longitudinally before placement into the duct
Dissolvable suture such as Vicryl or chromic is used to secure the T-tube with one stitch distal and one proximal to the tube
A drain should be placed in the foramen of Winslow after CBD exploration
Conversion to open CBD exploration is acceptable when inflammation is great, the surgeon is unfamiliar with laparoscopic suturing techniques, or exposure is not good
A Kocher maneuver is performed in open CBD exploration to take down the lateral peritoneum lateral to the duodenum, allowing traction on the common duct
A Kocher maneuver cannot be done laparoscopically
For stones impacted at the papilla, transduodenal sphincteroplasty can be performed by making a duodenotomy over the papilla and opening the papilla at the 11 o'clock position a few millimeters at a time
Transduodenal sphincteroplasty is not very common anymore
Many instruments for CBD exploration can be obtained from the urology cart because urologists use similar items for the ureter and ureteral stones
The choledochoscope is an inexpensive tool which makes laparoscopic or open common bile duct exploration very easy
Choledocholithiasis is a disease that belongs to the surgeons, and ERCP should be used as an adjunct
Surgeons should be comfortable doing CBD stone exploration and management transcystically, laparoscopically, and open if needed
Elevated GGT and alkaline phosphatase indicate obstruction of the common bile duct
Common bile duct dilation greater than 7 millimeters on ultrasound suggests obstruction, potentially with stones
If there is any question that there may be remaining stones in the bile duct or distal high pressure at the papilla, a T-tube should be used to decompress the duct, allow healing, and provide access for retained stones
The T-tube is removed 10 days to 2 weeks later, even in the office
If the duct is very dilated, very filled with stones, or distal stones cannot be removed, a drainage procedure (choledochojejunostomy or choledochoduodenostomy) should be considered