Management of Choledocholithiasis with special reference to use of Choledochoscopy.

Sugumar, C (2007) Management of Choledocholithiasis with special reference to use of Choledochoscopy. Masters thesis, Madras Medical College, Chennai.


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INTRODUCTION : Gall stone disease affects people from every society, race, gender and age group. More than 95% of biliary tract disorders are related to gallstone. Most bile duct stones are stones that have passed into bile duct from the gallbladder. Choledocholithiasis means stones in the bile duct. Stones are non crumbling concretions larger than 2mm in diameter and biliary microlithiasis are particles 2mm or less in diameter although there is no universally accepted definition. Sludge is suspension of cholesterol monohydrate crystals, calcium bilurubinate granules, and or other calcium salts with or without microlithiasis of gall bladder mucus. Sludge is a form of gall stone disease and may predispose to macroscopic stones or directly cause pancreatitis and other morbidity. Despite good surgical techniques,about 8% to 16% of patients have retained stones in common bile duct after conventional choledocholithotomy. Common bile duct stone is defined as retained if they are discovered within two years of cholecystectomy or recurrence if they are detected more than two years after cholecystectomy. To reduce the incidence of retained stones in the common bile duct, operative flexible choledochoscopy was introduced into clinical practice in 1970’s. Moreover surgery has been associated with a discouragingly high incidence of residual stones .Many studies since then have confirmed the value of flexible choledochoscopy as a reliable method of reducing the incidence of retained biliary tract stones.The reported incidence varied between 0% to 7% . In India, limited study is available regarding the use of operative choledochoscopy in the management of choledocholithiasis. ERCP facilities are not available in many centres and requires the expertise of a medical gastroenterologist. In contrast, operative choledochoscopy is a simpler procedure that can easily be learnt and practised by many surgeons at the time of exploration of common bile duct. This study was undertaken with an aim to investigate how flexible choledochoscopy lowered the incidence of retained stones in the common bile duct after the exploration. AIM : 1. To evaluate the role of operative flexible choledochoscopy after choledocholithothomy / transcystic choledochoscopy in reducing the incidence of retained stones in the common bile duct. 2. To study the epidemiology and clinical features of choledocholithiasis. 3. To study the surgical modes of management of common bile duct stone. 4. To study the operative finding in terms of gall bladder / common bile duct stone 5. To study the complications of surgical procedures 6. To study the role of T tube cholangiogram, ultrasound, magnetic resonance cholangio pancreatogram in detecting any retained stones in the common bile duct. MATERIALS AND METHODS : The patients who had their common bile duct explored for proven common bile duct stones during three years period from 2004 to 2007 were reviewed prospectively at Government General Hospital, Chennai in Department of Surgical Gastroenterology. During this period forty four patients with confirmed common bile duct stone with or without gallstones were chosen. Initial decision to explore the common bile duct was made by ultrasound in 20patients(45%), ERCP in 8 patients(18%), CT in 10 patients (23%), MRCP in 6 patients (14%) is given in Figure1. In addition, inclusion criteria and exclusion criteria were used to select the patients for common bile duct exploration using flexible choledochoscopy. CONCLUSION : It is now well established that choledochoscopy reduces the incidence of retained common bile duct stones in patients with choledocholithiasis. Hence we recommend that operative choledochoscopy should always be done after exploration of the common bile duct stones to reduce the incidence of retained stone. Surgical exploration of CBD with conventional method without the use of choledochoscopy have shown 8 to 16% of patients with retained stones . With the use of choledochoscopy, the incidence is reduced to 2% as quoted in various studies. In our study percentage of retained stone after flexible choledochoscopy was (2.27%) . Females were commonly affected by choledocholithiasis. The commonest age group was between 51-60yrs. Commonest complaint was pain or jaundice Though the gold standard in the management of choledocholithiasis is precholecystectomy or postcholecystectomy ERCP and sphincterotomy and retrieval of stones. Conventional use of choledochoscopy gives equivalent results as that of ERCP in the diagnostic and management of CBD stones. Hence in centers where ERCP facilities are lacking, flexible choledochoscopy plays a major role in reducing the retained stones in CBD. Since patients with choledocholithiasis may be completely asymptomatic, choledochoscopy should be done as a routine in suspected patients. Choledochoduodenostomy, Choledochojejunostomy, T tube drainage & primary closure of CBD after CBD exploration with flexible choledochoscopy has a definitive role in the management of choledocholithiasis. Post operative MRCP has played a major role in detecting stones even smaller than 4mm. Hence MRCP should be used as a preoperative and post operative evaluation of choledocholithiasis.

Item Type: Thesis (Masters)
Uncontrolled Keywords: Choledocholithiasis ; Management ; Choledochoscopy.
Subjects: MEDICAL > Surgical Gastroenterology and Proctology
Depositing User: Kambaraman B
Date Deposited: 27 Jul 2017 03:39
Last Modified: 27 Jul 2017 05:28

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