Background: Common bile duct stones are present in approximately 5% of the patients undergoing elective cholecystectomy and 10% of patients with acute cholecystitis with different modality of treatment. This study investigated&nbsp; edoscopic and surgical management and outcome&nbsp; of CBD stones among Sudanese patients at Ibn Sina Hospital October 2018 to October 2019.
The study included 68 patients. Data was collected using a constructed structured pretest questionnaire.
Objectives:To asses the outcome of endoscopic versus surgical management of common&nbsp; Bile duct stones.
Methods and patients:This is a hospital based descriptive cross-sectional study, which was conducted in Ibn Sena Specialized Hospital over a period of one year October 2018 to October 2019 .
Results:68 patients involved in the study , male to female ratio 0.6:1,the mean age was 61.2 years , patients underwent surgical management were 51.5%, patients underwent endoscopic management were 48.5%,multiple stones&nbsp; found in 73.5%,single stone found in 26.5%,stone found to be more than 1 cm in 41.2% less than 1cm in 58.8%,the success rate in achieving bile duct clearance in surgical group was 100% and in endoscopic group was 75.7%,complications developed in surgical group was wound infection in 2.85%,complications developed in endoscopic group was cholangitis&nbsp; 9%,in adequate clearance with stenting 9%and failure of Ercp in 15.1%,prolonged hospital stay in surgical group in&nbsp;&nbsp; comparison to endoscopic group&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp;&nbsp; .
Conclusion:Surgical interventions were superior in achieving bile duct clearance there was significant correlation between size and number of stones and endoscopic failure and management

alhaboob, Nassir

altayeb, Abdelmoneim

Balla, Talal Salah

Musaad, Abdulmagid Mohammed

English

Journals Of University Of Gezira

Gezira Journal of Health Science 16 (2):  27-35  (2020) 27   Endoscopic Versus Surgical Management  and Outcome of CBD Stones 2020  Talal Salah Balla 1, Abdulmagid Mohammed Musaad 2, Nassir alhaboob 3     , Abdelmoneim altayeb 4  1. Registrar of general surgery Khartoum Sudan 2. FRCSI, Professor of GI surgery, Faculty of Medicine, Omdurman Islamic University Department of GI Surgery, Ibn Sina specializ hospita 3. MD, MRCS-ED, Assistant professor of surgery, Faculty of Medicine, Omdurman Islamic University, Department of GI Surgery, Ibn Sina Specialized hospital,consultant physician Gastroenterologist 4. Department of gastro enterology ,Ibn sina hospital  Corresponding author:  Talal Salah Balla, email : tallal-000@hotmail.com    Abstract: Background: Common bile duct stones are present in approximately 5% of the patients undergoing elective cholecystectomy and 10% of patients with acute cholecystitis with different modality of treatment. This study investigated  edoscopic and surgical management and outcome  of CBD stones among Sudanese patients at Ibn Sina Hospital October 2018 to October 2019.  The study included 68 patients. Data was collected using a constructed structured pretest questionnaire.  Objectives:To asses the outcome of endoscopic versus surgical management of common  Bile duct stones. Methods and patients:This is a hospital based descriptive cross-sectional study, which was conducted in Ibn Sena Specialized Hospital over a period of one year October 2018 to October 2019 . Results:68 patients involved in the study , male to female ratio 0.6:1,the mean age was 61.2 years , patients underwent surgical management were 51.5%, patients underwent endoscopic management were 48.5%,multiple stones  found in 73.5%,single stone found in 26.5%,stone found to be more than 1 cm in 41.2% less than 1cm in 58.8%,the success rate in achieving bile duct clearance in surgical group was 100% and in endoscopic group was 75.7%,complications developed in surgical group was wound infection in 2.85%,complications developed in endoscopic group was cholangitis  9%,in adequate clearance with stenting 9%and failure of Ercp in 15.1%,prolonged hospital stay in surgical group in   comparison to endoscopic group                                                 . Conclusion:Surgical interventions were superior in achieving bile duct clearance there was significant correlation between size and number of stones and endoscopic failure and management.  Keywords :CBD stone ,ERCP,Surgical interventions     Endoscopic Versus Surgical Management and Outcome of CBD Stones 2020 28  Introduction : Cholelithiasis is a common surgical problem which makes cholecystectomy one of the most frequently performed surgical procedures. CBD stones complicate the working and management of cholelithiasis necessitating additional diagnostic and therapeutic procedures and adds to morbidity and mortality of gall stone disease. Common bile duct stones are present in approximately 5% of the patients undergoing elective cholecystectomy and 10% of patients with acute cholecystitis. No single blood test or combination of blood tests can predict whether or not a CBD stone is present. Intraoperative cholangiography is a gold standard for diagnosis , but CBD stones can be diagnosed preoperatively with ultrasound, ERCP or MRCP. If CBD stones are diagnosed preoperatively, several different treatment modalities can be utilized. The factors that determine the optimal approach include the patient’s age and general condition. It is also important to consider the local expertise of the Surgeon and the gastroenterologist in managing CBD stones. Hence the algorithm for managing these patients will vary from one location to another. There are specific indications that mandate CBD open exploration and therefore, the practicing surgeon must be well versed in these techniques. Although the stones in the CBD may be silent, the development of symptoms is potentially serious; obstructive jaundice, ascending cholangitis, acute pancreatitis are all associated with serious morbidity and at times, mortality which need immediate attention(1). Patients and Methods:  This was a across sectional retroprospective study, hospital based ,and was conducted at Ibn Sna Hospital from October 2018 to October 2019.  All patients who presented with CBD stone and accepted to participate in the study were included  , data collected using a constructed structured questionnaire and hospital records. 68 patients participated in the study  with clinical and radiological features of CBD stones and they received various treatment modalities surgical and endoscopic.The age and sex distribution, clinical presentation, diagnostic modalities, different therapeutic modalities and associated complications were all evaluated and compared with standard published literature. Results: The total number of patients included in the study was 68; the mean age was 61.7±2.6 years (Figure 1). Male to female ratio was 0.6: 1 (Figure 2).  All patients presented with obstructive jaundice  as shown in  (Table 1).  41.2%29.4% 29.4%0.0%10.0%20.0%30.0%40.0%50.0%60.0%30-50 years 50-60 years more than 60 years% Talal Salah Balla 1, Abdulmagid Mohammed Musaad 2, Nassir alhaboob 3     , Abdelmoneim altayeb 4  29  Table (1) presentation  Presentation  N % obstructive jaundice 68       100.0  Pain without jaundice 0 0.0 Jaundice with cholengitis 5           7.4  Silent 0 0.0   36.8%63.2%male female    Figure (2) gender  Some Patients developed pancreatitis  and other  some had a history of cholecystectomy(Table 2).    Table (2) development of pancerititis and history of cholecystectomy     N % patient developed pancreatitis yes 1 1.5  no 67 98.5 Total  68 100.0 history of cholecystectomy yes 1 1.5  no 67 98.5 Total  68 100.0   U/S and MRCP were the predominant investigation tool as shown in  (Table3 ).   Table (3) Investigations done    N  % kind investigation done U/S and MRCP 68 100  ERCP 46 67.6 history of ERCP yes 13 19.1  no 55 80.9  Endoscopic Versus Surgical Management and Outcome of CBD Stones 2020 30  Multiple stones found in the majority of patients and the Size is less than 1 cm in fourty patients  (Table 4).   Table (4) characteristics of the stone    N  % multiple stone or single multiple 50 73.5  single 18 26.5 Total  68 100.0 size of stone less than 1cm 40 58.8  more than 1cm 28 41.2 Total  68 100.0  The primary duct clearance was done by CBD exploration in 35 patients and the rest by ERCP (Table5 ).  The type of endoscopic management received was sphincteromtomy with basket stone extraction with balloon dilatation in 25  patients and some had stent in  (Table5 ).  The type of surgical intervention was choleduco enteric bypass in the majority of patients (Table5 ).  Table (5) interventions    N % primary duct clearance  ERCP 33 48.5  CBD exploration 35 51.5 Total  68 100.0 CBD exploration after failure or difficulty of ERCP yes 13 19.1  no 55 80.9 Total  68 100.0  Endoscopic management they receive Stent 3 9  balloon dilation and sphincterotomy + basket stone extraction 25 75.7  failed ERCP 5 15.1 Total  33 100.0 Surgical intervention  CBD exploration+Ttube 4 11.4  Choleducoenteric bypass 31 88.6 Total  35 100.0  In endoscopic group the majority of cases ended with succesful bile duct clearance and part of them ended by failure of ERCP and aminority complicated by cholangitis as shown in  (Table 6). In surgical group  all patients ended by succesful bile duct clearance , the only complication is wound infection as shown in (Table 6).  Talal Salah Balla 1, Abdulmagid Mohammed Musaad 2, Nassir alhaboob 3     , Abdelmoneim altayeb 4  31    Table (6) Outcome of interventions   N % endoscopic group cholangitis 3 9  no complications(sucsess bile duct clearance) 25 75.7  Failed ERCP 5 15.1 Total   33 100 surgical group      wound infection 1 2.85  no complications 34 97.1 Total  35 100.0  The hospital stay in surgical group was 5 to 7 days in 97,1%(n34) and in 1 patiens was 2 weeks but in endoscopic group it was 24 hours in 91%(n30)  and for 3 patients was 3 days  9%. Size and numbers of stone significantly correlated with CBD exploration after failure of ERCP, and type of endoscope and surgical management and outcome of endoscope (P value < 0.05) (Tables 7 and 8).  Table (7) stone type correlation   multiple stone or sigle  multiple Single  pt underwent CBDexploration after failure or difficulty of ERCP N % N % P value  Yes 9 18.0 4 22.2 0.017* No 41 82.0 14 77.8  what kind of edoscopic management they receive  Stent 2 4.0 1 5.6 0.022* balloon dilation and sphincterotomy + basket stoneextraction 14 28.0 11 61.1  failed ERCP 5 10.0 0 0.0  what kind of surgical intervention they had?   CBD exploration+Ttube 1 2.0 3 16.7 0.036* Choleducoenteric bypass 28 56.0 3 16.7  complications developed in endoscopic group   Cholangitis 3 6.0 0 0.0 0.001* no complications 47 94.0 18 100.0        Endoscopic Versus Surgical Management and Outcome of CBD Stones 2020 32  Table (8) Stone size correlation   size of stone  less than 1cm more than 1cm  pt underwent CBDexploration after failure or difficulty of ERCP N % N % P value  Yes 7 17.5 6 21.4 0.019* No 33 82.5 22 78.6  what kind of edoscopic management they receive  Stent 0 0.0 3 10.7 0.027* balloon dilation and sphincterotomy + basket stoneextraction 14 35.0 11 39.3  failed ERCP 0 0.0 5 17.9  what kind of surgical intervention the had?   CBD exploration+Ttube 1 2.5 3 10.7 0.018* Choleducoenteric bypass 25 62.5 6 21.4  complications developed in endoscopic group   Cholangitis 1 2.5 2 7.1 0.025* no complications 39 97.5 26 92.9   Significant (P value < 0.05)   Statistically were negative correlation between the character of stone and outcome of surgical management in one hand age and gender on the other hand (P value < 0.05) (table 9 and 10).   Table (9) Age correlations   Age 30-50 years 50-60 years more than 60 years  multiple stone or sigle N % N % N % P value  Multiple 24 85.7 14 70.0 12 60.0 0.065* Single 4 14.3 6 30.0 8 40.0  size of stone       less than 1cm 20 71.4 11 55.0 9 45.0 0.176* more than 1cm 8 28.6 9 45.0 11 55.0  complications developed in endoscopic group     Cholangitis 1 3.6 1 5.0 1 5.0 0.087* no complications 27 96.4 19 95.0 19 95.0  Not significant (P value > 0.05)        Talal Salah Balla 1, Abdulmagid Mohammed Musaad 2, Nassir alhaboob 3     , Abdelmoneim altayeb 4  33  Table (10) Sex of the patients correlations   sex  male female P value  multiple stone or sigle N % N % Multiple 15 60.0 35 81.4 0.073* Single 10 40.0 8 18.6  size of stone     less than 1cm 12 48.0 28 65.1 0.069* more than 1cm 13 52.0 15 34.9  complications developed in endoscopic group   Cholangitis 1 4.0 2 4.7 0.077* no complications 24 96.0 41 95.3   25 100.0 43 100.0  Not significant (P value > 0.05)    Discussion:  This is a cross sectional descriptive prospective study of endoscopic versus surgical management of CBD stones from march 2018 to march 2019 at Ibn sina hospital .The total number of patients included in the study was 68 patients with female predominance (male : female ratio 0.6:1 )  which is found relevant to Redwan and Omer study with female predominance 1.6 : 1 (2),  and Abdalrawof  who concluded that female were 58.5% (3) unlike  Durga who found that there was increased incidence in male ( M :F 1: 0.94 )( 4) .In our study the mean age was 61.7 as in Redwan and Omer the mean age was 40 years (2). All patients presented with obstructive jaundice 100% and some of them complicated by cholangitis 7.4 % and pancreatitis 1.5 % and history of cholecystectomy in one patient 1.5 % . Durga  found that the main presenting symptoms was abdominal pain , jaundice and  sometimes fever (4), Abolfazl Shojaiefard, Majid Esmaeilzadeh study show biliary colic and jaundice were the main presenting feature 12 . U/S and MRCP were the imaging modalities used in our study in all patients 100 %. Gianpiaro et al a study about the accuracy  of MRCP, EUS and U/S in detection of CBD stones (5) . In our study 35 patients were subjected to surgical intervention in form  of  choledochcoenterestomy ( n= 31) and CBD exploration with T tube . the success rate of achieving bile duct clearance was 100% with complication developed in one patient in form of wound infection in comparison to Adam who concluded that the incidence of retained CBD stones after CBD exploration with T tube was 15 %. wound infection was 5 % in T tube group in comparison to choleducodedunostomy which is 3.4%(6)                 . Ali et al , a prospective study of 83 patients which compared two methods for surgical management of CBD stones. In group I, 6 patients developed residual stones in CBD, reoperation was required for 3 of them and endoscopic retrograde cholangiopancreatography with sphincterotomy for another 3 patients, while in the other group (group II) 2 patients suffered from ascending cholangitis and were managed conservatively. No missed or residual CBD stones were developed and no patients need reoperation  (7),  Ravi et al a study of  60 patients who underwent CBD exploration with T tube , 34 patients had no complications. 3 Endoscopic Versus Surgical Management and Outcome of CBD Stones 2020 34  patients had wound infection. In 4 patients along with wound infection cholangitis and sepsis (1 each), pancreatitis in one  patient and bile leak in one patient was observed.                In our study the success rate in achieving bile duct clearance with ERCP is 75.7% with inadequate clearance and stenting in 9% and failure of cannulation in 15.15% , complications developed in 3 patients in form of cholangitis 9%(8) , Gad et al studied 94 patients of whom 76 (78.8%)and 18(21.2%) underwent single and multiple ERCP  sessions respectively ,and impacted stone is the most common cause of failure of ERCP in (60%)(9).                                                     Laszlo Lakatos et al concluded that The rate of successful     cannulation for ERCP was (97.1%). Bile duct stones were       detected in 81 patients (39.3%), and successfully removed    in 79 (97.5%)(10).                                                                                       In our  study size and number of stones were significantly related to surgical intervention after failure of ERCP and to endoscopic management and outcome of endoscopy (p value<0.05).  Ravi MJ et al found that stone size and number had major impact in the endoscopic outcome as he studied 60 patients, 59 patients underwent ERCP and in 01 patients ERCP was not attempted. In 45 patients stones were extracted successfully with complete clearance of CBD. There was 4 of these patients had stones measuring between 11mm to 14mm. Mechanical Lithotripsy was used to reduce the size of the stones in these 4 patients. Stones were extracted using basket with or without endoscopic sphincterotomy. In 2 patients CBD could not be cannulated . there was 8 patients had failed ERCP. there was 4 of these patients had stones measuring more than 12mm and multiple and in 2 patients impacted stones and other 2 patients had oedematous papilla. were the cause for failure. In 6 patients complete CBD clearance could not be achieved. All these patients were having multiple CBD stones and stones measuring more than 12mm.Smaller stones were extracted using basket. One patient had impacted large stone(8) .                                                                                                                    Mohamed rizwan et al who studied 60 patients with retained stones and treated with ERCP which was failed in 15 patient due to large size of the stone in 6 (40%),Technical difficulty in cannulation 3 (20%), impacted stone in cystic duct remnant 1(6%) , periampullary diverticulum 2(13%) ,patient unable to tolerate procedure2(13%)(11)                        . .                                                In our study the hospital stay is more prolonged in surgical group5 to 7 days in 97,1%(n34) and in 1 patients was 2 weeks but in endoscopic group its 24 hours in 91%(n30) and for 3 patients was 3 days  9%, Which is relevant to Gad who concluded that hospital stay is prolonged in surgical group in comparison to endoscopic group( 9)                                                                           Talal Salah Balla 1, Abdulmagid Mohammed Musaad 2, Nassir alhaboob 3     , Abdelmoneim altayeb 4  35  References :  1. Kalavant A. Aclinical study and management of CBD stone, Bangalore medical college and research institute, Bangalore (doctoral dissertation ) 2012. 2.  Redwan AA, Omar MA. Common bile duct clearance of stones by open surgery, laparoscopic surgery, and endoscopic approaches (comparative study). The Egyptian Journal of Surgery. 2017 Jan 1;36(1):76. 3. Abdel-Raouf A, Hamdy E, El-Hanafy E, El-Ebidy G. Endoscopic management of postoperative bile duct injuries: a single center experience. Saudi journal of gastroenterology: official journal of the Saudi Gastroenterology Association. 2010 Jan;16(1):19. 4. Prakash KS. Clinical study of surgical jaundice (Doctoral dissertation, RGUHS). 5. Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P, Barthet M, Domagk D, Dumonceau JM, Gigot JF, Hritz I. Endoscopic management of common bile duct stones: European Society of Gastrointestinal Endoscopy (ESGE) guideline. Endoscopy. 2019 May;51(05):472-91. 6. Adam RY, Musaad AM, Arabi NA. Choledochotomy with T-Tube versus Choledochoduodenostomy in Management of Patients with Common Bile Duct Stones at Ibn Sina Specialized Hospital= شق الصفراء مع T- أنبوب مقابل تشوليدوكودودينوستومي في إدارة Sudan Medical .المرضى الذين يعانون من الحجارة القناة الصفراوية المشتركة في مستشفى ابن سينا التخصصيJournal. 2017 Aug;11(5291):1-5. 7. Ali MM, Helmy MZ, Gomaa E. Choledochoduodenostomy versus T-tube drainage in patients have stones in common bile duct with risk factors of post-operative missed stones. International Surgery Journal. 2019 Nov 26;6(12):4343-7. 8. Ravi MJ. The efficacy of endoscopic and surgical management of CBD stones in terms of outcome, morbidity and mortality. International Journal of Surgery. 2019;3(2):77-81. 9. Gad EH, Zakaria H, Kamel Y, Alsebaey A, Zakareya T, Abbasy M, Mohamed A, Nada A, Abdelsamee MA, Housseni M. Surgical (Open and laparoscopic) management of large difficult CBD stones after different sessions of endoscopic failure: A retrospective cohort study. Annals of Medicine and Surgery. 2019 Jul 1;43:52-63. 10. Lakatos L, Mester G, Reti G, Nagy A, Lakatos PL. Selection criteria for preoperative endoscopic retrograde cholangiopancreatography before laparoscopic cholecystectomy and endoscopic treatment of bile duct stones: results of a retrospective, single center study between 1996-2002. World Journal of Gastroenterology: WJG. 2004 Dec 1;10(23):3495. 11. Khan MR, Naureen S, Hussain D, Azami R. Management outcome of residual common bile duct stones at Aga Khan University Hospital. Journal of Ayub Medical College. 2005;17(3):7. –  12.  Shojaiefard A, Esmaeilzadeh M, Ghafouri A, Mehrabi A. Various techniques for the surgical treatment of common bile duct stones: a meta review. Gastroenterology research and practice. 2009;2009.   

Endoscopic Versus Surgical Management  and Outcome of CBD Stones 2020

http://journals.uofg.edu.sd/index.php/gjhs/article/download/1691/1565

Endoscopic Versus Surgical Management and Outcome of CBD Stones 2020

Abstract

Similar works

Full text

Available Versions

Journals Of University Of Gezira