الفهرس | Only 14 pages are availabe for public view |
Abstract SUMMARY AND CONCLUSION Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10% of the adult population. CBDSs develops in about 8%-20% of patients having gallbladder stones, but in about 5% of cases the gallbladder is empty. One of the main reasons of investigating a patient with gallstones prior to cholecystectomy is to exclude the presence of associated CBD stones. All investigations are aimed at evolving a minimally invasive approach with the least number of complications achieved in a cost effectiveness manner to achieve a low overall morbidity of treatment. CBD stones are suspected if there is a history of pancreatitis or cholangitis, or there is increased serum levels of conjugated bilirubin, SGPT, SGOT and alk. phosph., or if there is dilatation of CBD more than 8mm or stone in the CBD at abdominal sonography or the presence of stones in the CBD at MRCP. The management of CBD stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology the main options for treatment are pre- or postoperative ERCP with endoscopic biliary 122 Summary & Conclusion sphincterotomy (EST), laparoscopic trans-cystic exploration of common bile duct and laparoscopic choledochotomy. The treatment of common bile duct stones has shown considerable evolution over the last 4 decades. The cause for this evolution has been constant up gradation of technological capability, which allows treating clinicians to offer cure. ERCP has been the gold standard for preoperative diagnosis of choledocholithiasis. It has the advantage of providing a therapeutic option when a stone is identified. Successful cholangiography by an experienced endoscopist is achieved in greater than 90% of patients. Complications associated with ERCP can be as high as 15% and include pancreatitis, cholangitis, perforation of the duodenum or bile duct and bleeding. The morality rate of ERCP is 0.2-0.5% Laparoscopic CBD exploration may be done after initial confirmation (detection) of a stone by IOC laparoscopic ultrasound. The cystic duct is dilated with graded dilators, balloon dilatation and Choledochoscopic stone removal is done. The same limitations to transcystic intervention are applicable in laparoscopy as well. Alternatively the CBD may be approached by a choledo-chotomy where the CBD is opened with scissors or a harmonic scalpel and the CBD explored using 123 Summary & Conclusion a therapeutic choledochoscope. Alternatively Steerable catheters under fluoroscopic guidance are used. Laparoscopic ante grade sphincterotomy may be added to provide bile duct drainage and to prevent the problem of recurrence. Various combinations of methods are available in the management of choledocholithiasis and should be tailored accordind to the patient’s criteria, surgical expertise, combined with the availability of the specific technology needed for each procedure. There are many interventions techniques under trial as lithotripsy and ESWL used in the treatment of difficult cases of CBDS that can’t be managed with the usual methods. |