Hey there listeners, this is Rod from Cincinnati Children's. Have you downloaded the new version of the Stay Current app? If not, check it out. There's so much new content on there, brand new layout, you're absolutely gonna love it. But until then, enjoy the episode. Cholodocholithiasis. I think it's so cool because it's one of those disease processes that spans multiple specialties, GI and surgery, and then we get to work on these complex patients together. I love it. But, if you are a purist, if you want to be the true general surgeon, you have to have a handle on how to treat cholodocholithiasis by yourself. And that's what we're gonna talk about today. To do that, we brought in my friend Ray Hankey. She is a general surgery resident out at Penn State University. And she's gonna kick it off. When do you suspect cholidocholithiasis in the workup of a patient with suspected gallbladder disease? That's Doctor Jeff Ponsky. He's a general surgeon and endoscopist at the Cleveland Clinic. We get laboratory tests and imaging. All right, let's break down the first part. Laboratory tests. He's talking about LFTs, GGT, alk phos. Now if GGT and alk phos are elevated, you gotta think obstruction of the common bile duct. Now he also mentioned imaging, so that's gonna be a right upper quadrant ultrasound. If you see dilation of the common bile duct greater than 7 millimeters, you gotta think obstruction. Potentially with stones. If in that evaluation, we suspect choloidokcholithiasis, when do we move to ERCP versus an IOC in the operating room? Certainly if a patient comes in with deep jaundice or cholangitis, Remember that's jaundice, fever, right upper quadrant pain, sometimes sepsis, or the patient has what looks like gallstone pancreatitis. That's jaundice, abdominal pain, and elevated pancreatic enzymes. Those patients have to be looked at very carefully and are potential candidates to relieve common bile duct obstruction with emergency ERCP. OK, but what if the patient's pancreatitis gets better like the next day? There is no rush to do the ERCP. At most institutions, ERCP is. Going to be the next step for any patient with cholodocholithiasis, and Jeff loves doing ERCP. However, it's definitely overused. And if a patient can go to the operating room and have an intraoperative cholangiogram and management of the common bile duct stones in one episode, they may be better off than having a preoperative ERCP. Assuming you don't have access to an expert endoscopist, how can we approach clearing the CBD? The first thing to do in the management of a patient with suspected common bile duct stones is to get an intraoperative cholalangiogram. We have to dissect out the cystic duct, put on your lead, shoot your shot, and once we get the cholangiogram, then we decide what we see and how we're going to approach it. OK, so then we got some options. Number 1, we can refer the patient for later ERCP. How about option number 2, Tracystic exploration of the Common duct with removal of stones if they're amenable to this. Door number 3, we can do a laparoscopic choleidotomy, opening the common duct and taking out the stones. And if you can't do it laparoscopically, or even an open common bile duct exploration. What if the common bile duct is so jam-packed with stones and it's humongous, then you might want to treat the patient with a choliogo duodenostomy or drainage procedure. How would you proceed with a cholecystectomy in a patient that you suspect might have CBD stones? Like any other laparoscopic cholecystectomy, we would isolate the gallbladder, take down the adhesions to the infundibulu, and expose the cystic duct and cystic artery. It's imperative that this be done first. OK, you got a beautiful dissection, then what? We would then place a clip. On the uh gallbladder side of the cystic duct, make a small choleotomy and proceed with the intraoperative cholangiogram. All right, Jeff, talk me through your cholangiogram. We place a catheter into the small cystic duct opening and inject contrast material. This should be done with fluoroscopy and not static X-rays. When we see the stones in the cystic duct or common duct and they're very small, we can choose perhaps to remove them through the transcystic root. Oh, how does that work? The transcystic root is amenable to small stones, usually in the distal duct. We can dilate the cystic duct with a balloon or ureteral dilator. And then pass a choleidochoscope or even a basket. What else can we do? We can also flush or push tiny stones through the papilla of otter, using glucagon to relax the papilla of otter. OK, so let's say these stones are just so massive, they're so impacted, none of this stuff is working. What's the next step? It is not difficult to do a laparoscopic common bile duct exploration. Yeah, maybe for you, Jeff, I'm a 3rd-year resident. Talk to me about how you go about doing this. We clean more medially on the top of the bile duct, bluntly taking the loose tissue on top of it and stripping it down and medially until we expose the anterior surface of the common bile duct. Then, using the cystic duct as traction to pull the common duct slightly, uh, laterally and using either a scissors or a hook to open up the duct. We can make a small incision in the anterior surface of the common bile duct, perhaps 1 centimeter incision. And we can then let the bile escape from here. We can use uh Fogarty balloons or baskets and eventually koleidocoscope, both upward and downward, to be able to clear the stones from the common bile duct. Awesome. OK, so, how do we know that we've cleared all the stones? Like, what do you do? Once we think we've completed this, and we can pass our chooleidocoscope in both directions, even into the duodenum disc. We can then take a T tube, usually a 12 or 14 T tube. We cut the back wall off of the T tube, uh, slice it longitudinally, and then we put the entire T tube into the, uh, abdomen and put its arms into the duct, both proximally and distally. I usually use a dissolvable suture such as vicro or chromic. To put a stitch one distal to the tube and one proximal to the tube, and then bring the tube out through one of the trochar sites. We also then take out the gallbladder and put a drain in the foramen of Winslow and bring it out through one of the uh trochar sites. When would you in this process consider converting to an open CBD exploration? I think a surgeon has to choose what makes him most comfortable. And I think that when you look at the common duct, if the inflammation is great, if you're unfamiliar with laparoscopic suturing techniques and your exposure is not good, it's perfectly acceptable to open the patient. Either through a midline incision or a coocher incision. OK, what's something that we do in the open technique that we don't do in the laparoscopic technique? We do a Kocher maneuver where we take down the lateral peritoneum, uh, lateral to the duodenum so that we can put traction on the common duct by holding the duodenum and pancreatic. He in our hand that is helpful in exposing the common bile duct, something that you cannot do laparoscopically. And then you do the same thing we did from the laparoscopic approach. You're going to open the anterior surface of the common bile duct, you're going to flush it out. You're going to use a cold doco scope, baskets, Fogerty catheters, whatever. But, if there's any question, however, that there may be remaining stones in the bile duct or might be some distal high pressure at the papilla, then a T tube should definitely be used as this will decompress the duct, allow it to heal, and even allow access to the duct should there be a retained stone later on. The T tube is removed 10 days to 2 weeks later, even in the office. What do you do if the stone is impacted at the papilla and can't get it out? And that will happen occasionally when stones become impacted at the papilla, sometimes even in an open procedure with very diligent uh exploration of the duct, you'll find that they're absolutely stuck in the distal duct, and you have several choices here. One is the uh uh trans. Adenal sphincteroplasty and in that situation, we make a uh duodenotomy over the papilla. We then take small clamps and go into the 11 o'clock position and open the papilla a few millimeters at a time to lay it open, much as we would do with an endoscopic sphincterotomy and then take out the stones under direct vision in that way. This is not very common anymore, but it is something that the surgeon should be aware of. Finally, If the duct is very dilated, if it's very, very filled with stones, or if you cannot remove those distal stones, one might consider what we call a drainage procedure, either a cholidocojeinnostomy or a cholidocho duodenostomy, which can be done very simply once the duodenum is mobilized and uh provides permanent drainage. What instruments should we have on hand to be prepared for a laparoscopic CBD exploration? I think it's very important for any surgeon who at any time plans to explore the common bile duct. They have a small cart or a small little container with all the things they might need to explore the duct cholangiogram catheters, contrast material, dilating balloons for the cystic duct, and balloons and baskets for the common duct. Many of these. Items can be gained from the urology cart because they use these very similar items for the ureter and ureteral stones and in a, in a pinch, you can ask the urologist to come in and help you get you some of these instruments, but it's important to have these on a little cart, a little box, a fishing tackle box or something so you can use them in an emergency if you need them, but you should know where they are. As well as a koleidoscope. The koleidogoscope is an inexpensive tool which makes uh laparoscopic or open common bile duct exploration very easy. All right, Jeff, let's sum it up here. What do you want a trainee like myself to know about klodocolithiasis? I think that the trainees should understand that cholidocholithiasis is a disease that belongs to the surgeons, and to use ERCP as an adjunct is perfectly appropriate, but the surgeon should be comfortable in the end of the day doing exploration and management of common bile duct stones. We should know how to do it transcystically, and we should know. How to do it laparoscopically, uh, by exploring the common bile duct and open if needs be. The common bile duct belongs to the surgeon and the surgeon should feel very comfortable in approaching it and taking care of the maladies which afflict it. That's a wrap on the management and cholidoollithiasis. Thanks so much, Ray. And thank you, the listener. Did you enjoy the episode? Well, let's say hypothetically, you didn't, and you disagree with something Jeff said. If you're in the stay current app, scroll down under the media player, leave a comment, and you can tag Jeff Ponsky in that comment. It'll pop up on his phone, and he'll read why you think he was wrong about something he said. Or maybe you just do something different. That's fine, start a conversation in the app. Download Stay Current pediatric surgery in the Apple App Store, the Google Play Store, get a conversation going today. But until then, I'm Rod from Cincinnati Children's, and remember, knowledge should be free.
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