【正文】 lecystitis/pancreatitis ? Preoperative ERCP Intermediate riskMRCP Low riskUSS then LC Imaging ? Plain xray ? Ultrasound ? CT ? MRCP ? ERCP Ultrasound ? Most widely used ? Easy to perform ? Causes little disfort ? Avoid irradiation and contrast media ? High reliability of diagnosing gallbladder stones (95%) ? Variable reliability of detecting CBD stones 23%80% depends on body habitus and experience of sonographer Endoscopic ultrasound ? Studies using EUS to evaluate prior to ERCP ? Avoids cannulation of papilla and avoids the risk of cholangitis and pancreatitis ? Sensitivity 93% ? Specificity 97% ? Approaches ERCP with experience CT ? Sensitivity for CBD stones causing obstructive jaundice 75% ? Stones usually isodense with bile (not useful for assessment of cholelithiasis) ? CT cholangiogram – unsuitable in jaundice as contrast not excreted ? Important for imaging of pancreas if suspicion of malignant disease and other abdominal ans MRCP ? Detail now approaches ERCP ? Technique relies on the principle of imaging fluid columns that are static, better images with dilated ducts and flow artifact can give false positive results ? Sensitivity 95% ? Specificity 89% ? Accuracy 92% MRCP Advantages ? No irradiation ? Avoids plications of ERCP in 5%10% of patients Disadvantages ? Claustrophobic amp。 Williams et al, ANZ J Surg 1994) No single technique will be applicable to the management of all CBD stones Management of CBD stones ? Preoperative ERCP and laparoscopic CBD clearance have equivalent overall outes (Rhodes et al, Lancet, 1998) ERCP LCBDE CBD clearance 75%96% 90% Morbidity 13% 8% Mortality 1% 1% Pancreatitis 3% 1% (Tranter and Thompson, BJS, 2022) ? Patients who have a transcystic approach have a shorter hospital stay Options if laparoscopic transcystic exploration fails ? Ligate cystic duct, plete cholecystectomy and rely on postoperative ERCP ? Perform laparoscopic choledochotomy ? Laparotomy and open CBD exploration Options if laparoscopic choledochotomy fails ? Insert Ttube and extraction of stones after 6 weeks ? Postoperative ERCP ? Conversion to open CBD exploration Total choledocholithiasis 372 Transcystic bile duct clearance286 Failed Transcystic clearance86 Choledochotomy41 ERCP clearance45 Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) ←Trial Randomization Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) Operative Data (86 Failed Transcystic clearance) ERCP Choledochotomy P No. of stones (mean) Mean diameter of CBD (mm) Operative time: surgery (min) ERCPs / IOCs (min) Total (min) Bile duct closure Not applicable Primary 24 Antegrade stent 10 Ttube 7 Open conversions 1 1 No. having 2 ERCPs 11 0 Randomized trial in Brisbane (Nathanson et al, Ann Surg, 2022) Postoperative Outes (No Mortality) ERCP Choledochotomy P Bile leak 0 6 (2 settled, 3 ERCP, 1 reoperation) Pancreatitis Biochemical 4 3 Clinical (Glascow Score) 1 (2) 1 (4) Severe sepsis 1 1 Retained stone 2 (reoperation) 1 (ERCP) GI bleed 2 (transfusion) 0 Reoperation 3 3 Overall significant morbidity 6 (13%) 7 (17%) NS Hospital stay (mean, days) Recurrent or retained CBD stones ? Recurrent in 10% cases ? More mon in patients with primary duct stones, CBD 16mm and periampullary diverticula ? Retained stones found on Ttube cholangiogram best dealt with by ERCP ? Takes 6 weeks for tract to mature and allow percutaneous radiologically guided stone extraction or choledochoscopy successful in 95% and carries less risk of pancreatitis or haemorrhage Cholelithiasis Suspicion of CBD stones Selective perop cholangiogram No stones LC Routine perop cholangiogram Routine perop ERCP CBD stones CBD stones EST and duct clearance LC LCBDE OCBDE Postop ERCP Failure Failure Success Failure OCBDE LCBDE Failure Algorithm showing the available strategies for management of mon bile duct stones Shojaiefard A, et al. Various techniques for the surgical treatment of mon bile duct stones: a Meta review. Gastroenterology Research and Practice, 2022。 (177。 serum amylase value ＞ 3 normal (﹥ 360 U/L)。 normal serum amylase value Resolving choledocholithiasis Cholelithiasis。 ) 肝功升高 ； 血 AMS正常 膽源性胰腺炎 膽囊結(jié)石 ； 持續(xù)性腹痛 ； (177。 后 1/3項(xiàng) ) ； TB升高 ＜ 2倍 (177。 〔 (a+b)(c+d)(a+c)(b+d )〕 ~ 很好 ~ 一般 ~ 不好 GBS＋ CBDS可能性的評估及存在的問題 陽性預(yù)測值 PV＋ =a/(a+b) PV＋ ＝ 〔 pre sen〕247。 ? 以受試者工作特性曲線（ ROC曲線）拐點(diǎn)處為截?cái)嘀?，?sen和spe均較高的點(diǎn)。不受患病率的影響。 GBS繼發(fā) CBDS的診療策略：尚無一致性的流程？ EBM有望解決此難題？ GBS＋ CBDS可能性的評估及存在的問題 何時(shí)繼續(xù)試驗(yàn)？何時(shí)治療？治療方法選擇？ 試驗(yàn)原則： 應(yīng)用可能改變處理方案的試驗(yàn)。 ()=1/9 AOC的 LR+==18 LR= 驗(yàn)后比 =驗(yàn)前比 LR+=1/9 18= 驗(yàn)后概率 =247。 ②本單位微創(chuàng)診療的手段： therapeutic ERCP、 MRCP、 IOC、 LC、LC+LCBDE。 ()=15/85 LR= = 驗(yàn)后比 =驗(yàn)前比 LR=15/85 = 驗(yàn)后概率 =247。 ()=15/85 LR= =9 驗(yàn)后比 =驗(yàn)前比 LR=15/85 9= 驗(yàn)后概率 =247。 ()=15/85 LR= =1 驗(yàn)后比 =驗(yàn)前比 LR=15/85 1= 驗(yàn)后概率 =247。 ()=15/85 LR= = 驗(yàn)后比 =驗(yàn)前比 LR=15/85 = 驗(yàn)后概率 =247。 考慮上述依據(jù)，參照上表和參考 AGSE(美國胃腸內(nèi)鏡協(xié)會2022)：？ High risk60% 肯定診斷 治療性 ERCP Intermediate risk30%~60% 中度可能 MRCP Low risk30% 不能確定 Laparoscopic IOC 何時(shí)繼續(xù)試驗(yàn)？何時(shí)治療？治療方法選擇？ 假定僅以 AOC (symptomatic CBDS)、 dilated CBD on US、 TB、 ALP為 CBDS的預(yù)測指標(biāo)。 18=1/144 轉(zhuǎn)化為率