Gallbladder Disease Flashcards
What is the incidence of choledocholithiasis if cholangiogram done routinely at time of cholecystectomy (with nL lab values)?
10%
What is the incidence of retained stones after cholecystectomy despite nL lab values?
1-2%
What percent of cholangitic people present with Charcot’s triad?
15-20%
Charcot’s triad / Reynold’s pentad?
Jaundice, RUQ pain, fever / +hypotension +AMS
How do you diagnose choledocholithiasis?
RUQ US = CBD > 6-8 mm, hepatic function panel, EUS (can proceed to ERCP), MRCP (may not detect stones/sludge < 6 mm).
What is the treatment of choledocholithiasis?
ERCP with sphincterotomy of deep Oddi muscles (if CI (bleeding risk), can do balloon dilation of ampulla), basket or balloon stone removal. Early cholecystectomy. (>48-72 hours)
What is the rate of success of ERCP for choledocholithiasis?
75% 1st time, 90% 2nd time.
What size CBD stone will pass spontaneously?
1cm or smaller
Balloon vs basket removal of CBD stone?
Basket = dilated duct with multiple stones
Balloon = normal ducts or single free floating stones
Mechanical lithotripsy = when multiple or large stones
What is the rate of ERCP complications?
10%
What are the types of ERCP complications?
Recurrence (MOST COMMON), pancreatitis, perforated bowel/duct, bleeding, infection, papillary stenosis (sphincterotomy), cholangitis
Timing of cholecystectomy after choledocholithiasis ERCP?
Within 2 weeks to decrease risk of recurrent biliary events and conversion to open cholecystectomy.
Before patient leaves the hospital.
What do you need for intraoperative cholangiogram and subsequent intervention?
0.0035 inch guidewire, water soluble contrast, 3-5Fr biliary fogarty catheter, wire basket, 8mm balloon, 7-12Fr dilators, 3-5 mm choledochoscope with 1.1mm or larger channel, loop ligatures and T tubes, C arm (left side).
How do you improve visualization during intraoperative cholangiogram?
To see proximally, IV morphine (contract sphincter of Oddi), occlude distal bile duct, Trendelenberg positioning.
Then to see distally, IV glucagon (relax sphincter)
When is a transcystic CBD exploration indicated?
Preferred in pt with small stones < 1cm, duct < 6mm, stone location DISTAL to junction of cystic/CBD and cystic duct > 4mm*.
Cannot do for CHD stones.
How do you perform a transcystic CBD exploration?
After confirmatory IOC, duct cannulated with wire.
Dilate or balloon the duct.
Flush CBD with saline DISTALLY (not proximally - don’t push stones up to liver).
Use balloon catheter 3-5Fr, advance into DUO, retract inflated balloon to ampulla, deflate/withdraw/inflate to pull back the stones.
Withdraw catheter SUPERIORLY along axis of CBD.
Try BASKET retrieval if balloon fails via scope (dilate if needed).
Finish with irrigation and then completion cholangiogram.
Close the cystic duct with loop > clip ligation.
if cannot visualize hepatic ducts on IOC?
- pull catheter back and flush
- trendelenberg reimage
What is the indication to make a direct choledochotomy laparoscopically in CBD exploration?
Narrow or tortuous cystic duct, dilated CBD 6-10mm, large >1cm or multiple stones, stones proximal to junction. All preclude transcystic approach.
What is the downside of choledochotomy for CBD exploration?
Longer OR time, longer hospital length of stay, more leak rates.
How to make the choledochotomy for CBD exploration?
Stay sutures around 1 cm incision below the cystic duct takeoff.
If T tube drainage 12-16 Fr tube is planned, make LONGITUDINAL incision.
If primary repair planned, make TRANSVERSE incision. Will need to close transversely since there are posterior attachments to duct that precludes mobilization.
Close with monofilament absorbable suture.
T tube vs primary closure of choledochotomy?
Primary closure is preferred (equivalent leak, decreased OR time, LOS). T tube may provide drainage when edema/spasm of sphincter is anticipated, but overall can increase leak rate, duct obstruction, infection.
How to expose in open CBD exploration?
Subcostal or midline incision.
Liver retracted superiorly.
Duo retracted inferiorly.
Omentum and stomach retracted to the patient’s left.
Kocherize duo to expose distal CBD.
Palpate duct and milk stone to incision at distal CBD.
1.5 cm incision with stay sutures.
Extract (balloon or basket) stone.
Postclearance cholangiogram via 18Fr T tube (trim obliquely proximally, lay distal limb just before the ampulla). Excise posterior wall of T tube to adi in removal. Bring tube out to costal margin.
Another cholangiogram.
When to remove the T tube?
3 weeks after OR; repeat T tube cholangiogram before removal to confirm patent flow.
if retained stone, repeat 6 weeks postop and then attempt removal (tract to mature)
Indication for transduodenal sphincteroplasty?
Provide drainage with nondilated biliary tree and stones impacted at the AMPULLA.