Gallstone Disease

Topic overview

This podcast is an interactive discussion about gallstone disease between Dr. Todd Ponsky and his father, Dr. Jeffrey Ponsky.

Dr. Jeffrey Ponsky is a professor of surgery at Cleveland Clinic Lerner College of Medicine, and is an expert in advanced therapeutic endoscopic treatment of biliary disease.

Intro track is adapted from "I dunno" by grapes, featuring J Lang, Morusque.
Artist URL: ccmixter.org/files/grapes/16626

• Dr. Jeffrey Ponsky: Professor of Surgery at Cleveland Clinic Lerner College of Medicine
• There is very little difference in the management of biliary disease (especially gallstones and cholecystitis) between children and adults
• Work-Up for Right Upper Quadrant Abdominal Pain
• History is important: nature, how it recurs, what brings it on, etc.
• RUQ Ultrasound
• Stones, pericholecystic fluid, and thickening of the gallbladder wall are all suggestive of biliary disease
• If the gallbladder appears normal and is without stones on ultrasound, a hepatobiliary iminodiacetic acid (HIDA) scan with a cholecystokinin (CCK) ejection fraction is useful
• This test evaluates for biliary dyskinesia; look for an ejection fraction less than 35%
• Case 1: 14-year-old overweight female
• Presents to the Emergency Department with a 24-hour history of abdominal pain in the RUQ, which is worse with eating; she has had similar episodes previously
• RUQ US shows pericholecystic fluid and a thickened gallbladder wall
• Labs show a slightly elevated alkaline phosphatase and a white blood cell count of 13
• This patient has acute cholecystitis, which is an indication for a cholecystectomy
• If there is no pericholecystic fluid or wall thickening, the patient instead has biliary colic; this patient could be discharged and could come back for elective cholecystotomy, without need for further imaging
• The sooner you can operate within the first week, the better the outcome
• For a patient who presents over the weekend, as long as the patient is without signs of peritonitis and is stable, it is up to the surgeon’s discretion whether they operate over the weekend or wait until Monday
• There is no evidence that antibiotics prior to the operation helps
• The patient can continue clear liquids as tolerated if waiting over the weekend
• Laparoscopic Cholecystectomy Tips and Tricks: Port Placement
• Laparoscopic cholecystectomy is a very challenging operation, where point of view and retraction are extremely important; this is made easier with four ports
• Umbilical port, with direct cutdown via the Hassan technique
• Epigastric port: just off the costal margin, to the right of the midline; placed under direct vision and placed to the right of the falciform; it should be angled enough to the left to allow for an easy shot at the gallbladder; place at the level of the left lobe of the liver; use this port for dissection
• Right lower quadrant port: in line with the anterior superior iliac spine; this port is placed before the final port is placed and the fundus of the gallbladder fundus is lifted superiorly to reveal the cystic duct
• Mid-clavicular port: placed after retracting the gallbladder fundus superiorly; if not, it will be too low; use this port to retract the gallbladder infundibulum
• For "A-frame” patients (skinny patients where the ribcage looks like an "A”), ports must be placed lower in order to avoid the ribs
• Do not rush to the cystic-common duct junction!
• Tips for the Difficult Laparoscopic Cholecystectomy
• Slowly take down the adhesions to the gallbladder; stay towards the gallbladder side and work down to the infundibulumIf the anatomy is not clear, you can do a modified dome-down; retract the dome, then start halfway up, then incise the peritoneum and work down on both sides until reaching the gallbladder-cystic duct junction
• Blunt dissection and hydrodissection with the suction-aspirator can be immensely helpful
• Once you think you have isolated the cystic duct and are dissecting between the duct and the artery, turn the hook towards the gallbladder, lift up on the peritoneum at the corner of the cystic duct, and then cauterize to gain an additional half-centimeter or centimeter
• Tips for the "Easy” Laparoscopic Cholecystectomy
• "Easy” cholecystectomies can be the ones where you make bad mistakes; there can always be accessory cystic ducts, problems with the cystic artery, etc., so slow down!
• Start at Calot’s triangle
• Take the peritoneum off the cystic duct with gentle pulling and tearing
• The hook cautery can be used to incise the lower side of the gallbladder, both laterally and medially, to get into the sub-peritoneal plane, which accentuates the cystic-gallbladder junction
• Tips and Tricks for Cholangiography
• Do you do one?
• It can help identify the anatomy and to make you better when trans-cystic exploration of the common bile duct is necessary
• If the cystic duct is small, there are normal liver function tests, and the gallbladder is otherwise normal, a cholangiogram is not necessary
• Always do for patients with a history of pancreatitis, an enlarged duct on ultrasound, or jaundice
• Use the Ponsky catheter!  Ureteral catheters can also be used
• After isolating the cystic duct close to the gallbladder, place a clip on the gallbladder side, then make an incision near the clip without transecting the duct
• Attach the catheter to a syringe with 10 mL of half-strength or full-strength and then flush it; place the catheter into the opening, then secure with the Olson clamp or another clip
• If the contrast only goes into the duodenum, that is "the cholangiogram from Hell”
• Using cinefluoroscopy, take the laparoscope, place it on the duodenum (where the papilla is located), press on it, and then inject contrast
• Same-Day Discharge?
• For adult outpatient surgery, 30 mg of Toradol in the operating room before they wake up allows for pain control and discharge from the PACU
• For pediatric patients, there is a growing trend towards same-day discharge, but many surgeons still admit overnight, or at least observe for several hours in the hospital
• Case 2: One Week of Symptoms
• Proceed with the same management plan as for a patient with 24 hours
• Instead, rely on clinical information; if there are CT or US findings that show a large amount of pericholecystic fluid or a fluid collection, it may be better to wait 4-6 weeks before operating
• Case 3: Excessive Post-Operative Pain
• If a patient calls you because of their pain after a laparoscopic cholecystectomy, something is wrong; have them come into the Emergency Department STAT, as it is a bile leak until proven otherwise
• In the ED, get a CT scan (or an ultrasound)
• If it shows a fluid collection, tap it; if there is bile in the fluid collection, the patient goes for an ERCP
• You need to evaluate for a common bile duct injury
• If there is a leak from the cystic duct, place a short, wide stent (10 Fr, 5 cm in adult patients), with or without sphincterotomy; bring them back 3-6 weeks later for stent removal
• If there is no fluid collection, send the patient for a HIDA scan, even if the liver function tests are normal
• Case 4: Biliary Dyskinesia
• Patient has chronic abdominal pain and a CCK HIDA scan, which shows a low ejection fraction
• If the rest of the patient’s work-up is negative, these patients should undergo cholecystectomy
• Case 5: Gallstone Pancreatitis
• Patient has abdominal pain, elevated bilirubin (mostly conjugated), and an elevated amylase and lipase
• They should be admitted overnight, hydrated, and kept NPO; ERCPs should not be obtained the day of admission, since two-thirds of ERCPs done at this time were normal; trend amylase and lipase
• If these values go down, there is no need for ERCP pre-operatively; once they normalize, perform a laparoscopic cholecystectomy and a cholangiogram; this should be performed during the same hospital stay
• If they do not go down, or if the patient has worsening signs of pancreatitis, perform an ERCP with a sphincterotomy
• Gallstone Pancreatitis: OR vs. ERCP
• For a surgeon who is not an expert in laparoscopic CBD exploration and who must send the patient to another facility for an ERCP, what should the management be?
• Patients who have persistently elevated bilirubin should have a pre-operative ERCP; they can be sent to the other facility
• However, this varies with the availability of ERCP at the institution; another option is to perform a laparoscopic cholecystectomy and cholangiogram first, and then send the patient post-operatively if the stone cannot be dealt with intraoperatively
• Maneuvers to Clear the Common Bile Duct
• Make an opening in the cystic duct and then milk back with the Maryland dissector
• Cholangiogram shows "a disc-shaped opacity right at the junction of the papilla;” this is the meniscus sign
• Give 1 mg (or 1 amp) of glucagon in an adult-sized child, wait 1-2 minutes, flush with saline, then repeat the cholangiogram
• If the meniscus sign is still present, take a soft-tipped wire, pass it through the cystic duct, and pass it into the duodenum under fluoroscopy
• The wire may dislodge small stones or reveal that a pseudo-meniscus sign is present
• The wire must be soft-tipped; always watch under fluoroscopy and never push against resistance in order to avoid perforating the duodenum
• If the stone is still present, using the choledochoscope next would be ideal; however, it is frequently unavailable
• In this case, take a closed Dormia basket and pass it into the duodenum; open it up slightly, pull it back a small amount without closing it, then jiggle the basket and pull it up
• A 5 Fr Fogarty balloon could be used in the same way; place it in the duodenum, blow up the balloon, pull it back until you feel the papilla, let it down for a millimeter, then pull it back, re-inflate it, and pull it back
• At this point, if the choledochoscope is available, pass it down the cystic duct, then grab it with a Dormia basket or put a Fogarty balloon past the stone under direct vision; either of these will trap the stone between the scope and the basket/balloon, and then pull it out through the cystic duct
• It is good to put Endoloops on the cystic duct stump
• Todd’s Takeaway: Gallstone Pancreatitis
• Admit overnight
• Watch amylase/lipase
• Improvement: Laparoscopic cholecystectomy
• No Improvement: Dealer’s choice
• Send out for ERCP
• Try trans-cystic exploration, then post-operative ERCP if unsuccessful
• Some will do a laparoscopic common bile duct exploration
• Laparoscopic Common Bile Duct Exploration
• Do not perform in a normal-sized duct; it should be dilated to at least 1-1.5 cm
• If it is normal-sized, send out for an ERCP in order to avoid injury stricture or injury
• Stay cool!  You can convert to open whenever you need to
• Do not divide the cystic duct; use the gallbladder to retract laterally, then use a blunt dissector or suction to wipe the cystic duct towards the CBD; the loose peritoneum and fat over the anterior service of the CBD will come off and reveal the junction of the cystic duct and the CBD
• Use an aspiration needle if unsure whether it is the CBD; bile should be easily returned
• Take the hook cautery or tiny scissors and make a small hole in the CBD, 1-2 mm superior to the junction of the cystic duct and CBD; then spread the incision to about 5 mm transversely, before going downwards with the incision towards the duodenum
• At this point, the stone frequently pops out on its own
• Take a 10 Fr red rubber catheter; put it down the CBD and flush, then put it up and flush
• If still no stone is extracted, use a 5 Fr Fogarty, again going up and down
• A choledochoscope can be used if there is still doubt about removal of the stone
• Doing a cholangiogram after opening the CBD is difficult but not impossible; you can place a T-tube through the opening, then perform a cholangiogram through the T-tube
• When closing, place an entire T-tube (12-14 Fr) into the abdomen and cut it about an inch on each side of the T, beveling the edges and cut half of the back wall off
• Put the bottom end in first, then bend it and pop the top end in
• Secure the T-tube with either interrupted or running absorbable suture
• Finally, remove the gallbladder, place a JP drain in the foramen of Winslow, and take the tail of the T-tube out through one of the ports with a tiny bit of laxity
• At 10 days, get a cholangiogram; if that looks okay, the T-tube can be removed a couple of weeks later
• Case 6: Severe Gallstone Pancreatitis
• Patient has gallstone pancreatitis; the gallstone passes, but they have severe symptoms from pancreatitis still; when should you operate?
• Getting a CT is helpful to determine if a phlegmon is present at the head of the pancreas; in this case, waiting six weeks is probably better
• Otherwise, do the operation after the pancreatitis has improved but before they leave the hospital
• Choledochoduodenostomy
• Occasionally, cholangiography will reveal many stones, going up into both the right and left hepatic ducts; this can be seen in patients with a propensity to form stones, such as those with sickle cell anemia
• In these patients, doing a laparoscopic or open choledochoduodenostomy is a good drainage procedure to allow stones to flow through the common bile duct easily
• Make the anastomosis large (about 2 cm)
• Case 7: Pericholecystic Phlegmon
• Patient with RUQ pain and CT/US findings of a phlegmon around the gallbladder
• If acutely ill, they may not be a good candidate for a laparoscopic cholecystectomy; instead, place a percutaneous cholecystostomy tube to temporize the patient, then return in six weeks
• If the patient has a clotting disorder, this may not be an option
• If an operation is necessary, a fenestrated cholecystectomy is an option
• Open the fundus, clean it out, remove the proximal gallbladder, and staple across it, leaving the distal gallbladder in place
• Alternatively, remove the anterior wall, then Bovie the backwall to kill the mucosa; clip the cystic duct if possible, but if you cannot see it, you can instead place multiple drains and settle for a controlled leak
• Pitfalls: Why Do CBD Injuries Occur?
• This most commonly happens for "easy” cases, where a cholangiogram is not performed, or the case is otherwise being done too quickly
• Sometimes the CBD will approach right next to the gallbladder and then takes a bend to the patient’s left up towards the liver, like a knee, and a small cystic duct then comes off
• Just because you can get around the structure does not mean that it is not the CBD; the cystic duct-gallbladder junction must be dissected perfectly
• Pitfalls: What to Do with a CBD Injury
• First: stop; this mistake could happen to any surgeon
• Call in a partner to examine it with you
• If you cannot perform a hepaticojejunostomy yourself, do not try; place drains to control the leak and then refer to a hepatobiliary surgeon
• Otherwise, the primary injury is compounded by the attempted repair
• If a small lateral injury to the CBD is found, place a small T-tube to control the leak, even if it means making the hole slightly larger; do not close the hole with a stitch
• Pitfalls: Complete CBD Transection
• Often you will not know you caused the injury
• If you do realize it, leave the duct alone, so that the person repairing it has enough tissue to work with; instead, place drains to control the leak

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