【正文】 duct or distal to the cystic duct entry Choledochotomy preferable if ? Large and/or numerous stones ? Common hepatic duct or intrahepatic ducts ? Careful consideration of laparoscopic strategies to be employed, equipment required and adequacy of assistance Indications for choledochotomy ? Unsuccessful transcystic exploration ? Cystic duct diameter smaller than stones ? CBD 8mm ? Multiple large stones ? Impacted stones with features of cholangitis ? Ampullary diverticulum on IOC ? Previous bilroth 2 gastrectomy ? Previous failed ERCP ? Contraindication to post postop ERCP ? ERCP unavailable Laparoscopic choledochotomy ? 35% of patients transcystic approach fails to clear the CBD ? Only absolute contraindication in a CBD 8mm ? Consider that 1/3 stones detected at IOC will pass spontaneously and exploration of a small duct may result in increased morbidity ? Surgeon must be appropriately trained Laparoscopic choledochotomy ? Deflate duodenum with NGT ? Extraport to retract duodenum ? Leave cholangiocatheter in place to prevent deflation of CBD ? Laparoscopic knife for choledochotomy ? Flushing, Fogarty catheter and basket to remove stones ? Once duct confirmed cleared (choledochoscopy) consider: ① T tube。 Ttube drainage alone associated with recurrence rates up to 41% ? Laparoscopic choledochoduodenostomyan option for advanced laparoscopic surgeon, but concerns regarding long term consequences of bilioenteric reflux Secondary bile duct stones ? Found at the time of or within 2 years of cholecystectomy ? 12% cholecystectomies ? 90% have preoperative indications (jaundice, pancreatitis or abnormal LFTs) ? 5%10% have no preop indication and are detected at IOC (filling defect, absence of filling terminal segment of CBD or delay/absence of flow into duodenum) The best management of CBD stones is still a matter of debate ERCP General agreement ERCP is preferable in ? Postcholecystectomy patients ? High risk surgical patients who still have a gallbladder ? Severe acute cholangitis ? Selected patients with acute biliary pancreatitis ? Failed transcystic exploration with a CBD 8mm ERCP Areas of disagreement ? First line management of CBD stones ? Preoperative CBD clearance ERCP ? CBD clearance 90%95% with successful sphincterotomy (papillary dilatation is an alternative) ? Overall clearance 80%95% (improves with experience of endoscopist) ? Major plications in 10% ERCP plications Acute (5%) ? Haemorrhage 1%6% ? Acute pancreatitis 1%19% ? Cholangitis ? Retroduodenal perforation 1%2% ? Failure to clear or access duct 2%18% Overall procedure mortality 1% 30 day mortality can reach 15% (reflects severity of underlying disease) ERCP plications Medium ? Recurrent stones 2%14% ? Cholangitis 1%6% ? Bacterobilia 60% Late ? Bile duct malignancy 2% (Prat et al, Gastroenterology, 1996 amp。 Narrow mon biliary duct(≤7mm on US) 2 2 2 Initial classification of suspected choledocholithiasis according to Cotton criteria as determined by ERCP and MRCP (Calvo et al, Mayo Clin Proc, 2022) Risk Stratification Factor Criteria Score Age ＜ 55years 0 ≥ 55years 1 Sex F 0 M 1 Jaundice Absent 0 Resolved 1 Current 2 Ascending cholangitis Absent 0 Present 3 Transaminases Normal 0 ＞ normal, but＜ double 2 Greater than double 4 CBD diameter (US) Normal 0 Dilated 3 CBD stone (US) Absent 0 Present 3 Predictive scores for each multivariate factor used to produce the scoring system (Menezes et al, BJS, 2022) Risk stratification High risk ifCBD 6mm 2 or more abnormal LFTs cholecystitis/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。 Moderate dilatation of the mon biliary duct (810mm) 9 9 9 Group 1 (low probability) Normal hepatic tests。 Dilatation of the mon biliary duct (10mm) 50 49 50 Group 2 (intermediate probability) History of stone migration (antecedents of cholangitis or biliary pancreatitis)。 排泄受阻 Risk stratification Risk stratification Cotton criteria No. of patients ERCP (No.) MRCP (No.) Group 3 (high probability) High risk due to cholangitis, pancreatitis, or jaundice。 另有胞漿內(nèi)游離部分 710d 同上，無黃疸不全梗阻也可顯著升高 100％升高，比 ALP更敏感 小膽管細(xì)胞合成更加 。 10h 判斷肝實質(zhì)損害的酶 70%90%可輕中度升高 膽道排出減少（極次要清除途徑）；繼發(fā)性的肝細(xì)胞損害（如ACST） AST 心＞肝 7000倍 2