CURRENT TRENDS IN MANAGEMENT OF CHOLEHOLITHIASIS[在管理胆总管结石目前的趋势](-35).ppt

“More Than You Bargained For〞Dr Asif Khan Case 138 y/o female.Rt upper quadrant pain and vomiting, deranged LFT’s (obstructive picture) PMH includesERCP Two stones 8 and 10mm identified but unable to remove, stent was placed and sphincterotomy performed.Laparoscopic Cholecystectomy MRCP 2007 Clinical ExamAfebrile, hemodynamically stable. Scleral icterus.Abdomen soft, mildly tender , negative Murphy’s sign. No rebound tenderness/guarding, no masses appreciated.Blood Results:WBC 4.6 x 109/L (4-10 109/L )AST 258 IU/L (14-54 ) ; ALT 352 IU/L (14-54)Billirubin 77 umol/L (3.4-20.5)Alkaline phosphatase 258 IU/L ( 42-121)INR 1.1 InvestigationsU/S – Dilated CBD (14mm) containing two stones, one 13 mm.ERCP attempted Blocked stent , dilated CBD , two large stones 1cm in size, small stones and sludge. Stent changed and surgical intervention suggested as stones unretrievable via ERCPMRCP – planning – pre IR Confirms ductal stones and dilated ducts Prominent ducts especially those beyond the stones in the right radicular duct system. Modified Burhenne PTC technique - feasible InvestigationsMRCP; to assess interventional approach Percutaneous ApproachRight PTC: Access ducts beyond incarcerated stone -a pre-requisiteStone Management PTC and cannulation guide wire techniqueModified “ Burhenne〞 techniqueOver the wire Fogarty Balloon - pushStones were pushed into the duodenum and stent inserted. CBD was cleared. PTC: Right needle access to biliary ducts - fluoroscopyStone Over the wire Fogarty Balloon 5 Fr “ Burhenne〞 - push Post Procedure Post interventional radiology, Patient made good recoveryDischarged home no further episodes. LFT’s normal. Case 2 72 y/o female.Admitted with RUQ pain , fever and jaundice.Clinical picture of Cholangitis treated with IV antibiotics ,fluid resuscitation and analgesia.Recurrent admission for symptomatic choledocholithiasis and repeated ERCP attemptsERCP 1 -failedERCP 2 -failedERCP 3 -failed