retained hepatic stone - Forum

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Grandpa Phil

retained hepatic stone - Ärzteforum

Post#1 »

I had a 79M with Charcot's fever. 3 yrs earlier he had a bleeding DU, with a perf DU 5 yrs previously(patched). I treated this with a B2 and tube duodenostomy because the doudenal stump was a piece of shit after I got done with it..(sorry for not doing a B1 ..we've already had this discussion, and maybe you can gloat on this one). Anyway, GB removed (open obviously..pt +++toxic) and 7 or 8 stones removed but one impacted in common hepatic duct. After 3 hrs I decided to bask in the success of simply draining the swamp instead of doing a meticulous census on the alligators (hope you like this Rick in Jacksonville). I couldn't disimpact this with choledoscopy, basket, or Fogarty. Inserted a T-tube and waited for post op radiological help. 4 week post op pt pulled out T-tube (probably low grade biliary sepsis with confusion) and I inserted a feeding tube into distal CBD. (Verified radiologically X2over 5 days). Radiological attempt at T tube extraction was complicated by feeding tube dislocation, and therefore a no go. Any thoughts at this point, as there is more to go on this story?...endobiliary access lost...


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A Doctor

Re: retained hepatic stone - Ärzteforum

Post#2 »

Retrograde ERCP, through the afferent loop, can be done successfully, in good hands. If the patient is not septic or jaundiced (the "impacted" stone is not really impacted)- then you have just started another for-surgeons.com mini-war whether to do anything at all.

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Surgeon

Re: retained hepatic stone - Ärzteforum

Post#3 »

Can you use lithotripsy for common bile duct stones? The type of lithotripser that was promoted for gallstones, similar to the common kidney stone lithotripsers?

Biliary surgeon

Re: retained hepatic stone - Ärzteforum

Post#4 »

This is a difficult and challenging problem, this common hepatic duct stone should be removed, ERCP can be done in patients with Billroth II gastrectomy, but it is technically demanding, if this can be done a wide papillotomy and dormia extraction of the stone can be performed. I know that it was difficult for you during open exploration of CBD to dislodge this stone, but it worth trial with the strong Olympus dormia baskets to engage the stone and extract it, if it was difficult to extract you can crush it with lithotripter. If you failed to engage the stone in the dormia then you can insert a nasobiliary tube to be used to locate the stone, by injecting dye into CBD, during extracorporeal shock wave lithotripsy.

If it was difficult to locate the papilla during ERCP, a percutaneous transehepatic route can be established and a guide wire can be passed percutaneously, by-passing the stone, to the duodenum where it can be retrieved by the scope and a papillotomy knife passed over the guide wire to do papillotomy and attempt the above steps.

If the guide wire could not pass the stone percutaneously, you can insert a drainage tube to be used for drainage of biliary tree and to locate the stone during extracorporeal shock wave lithotripsy, if this was successful, then you can pass a guide wire to the duodenum, use it for papillotomy to clear the biliary tree from stone fragments.

If all of the above failed, you will have two choices:
1- Leave the patient to his fate of recurrent attacks of cholangitis which will be fatal sooner or later.

2- Re-explore the patient, try to extract this stone by direct incision on it in the CHD, and the last option left is a hepaticojujenostomy.

Marcel

Re: retained hepatic stone - Ärzteforum

Post#5 »

At this point how was the jaundice, and more to the point were there any dilated ducts. If there were would a transhepatic approach be possible, dilating the tract and extracting the stone percutaneously? I suppose this might have been a situation where an access loop would have been useful at the time of the original op, rather than a T tube which when gone is gone - as you point out. I was taught in elderly with CBD stones to do a formal ductal drainage procedure rather than a T tube, though I can appreciate this might have been a bit of a spaghetti junction in this patient.

Grandpa Phil

Re: retained hepatic stone - Ärzteforum

Post#6 »

This old guy was a bit salty and had bilat orthostatic basal pneumonias, low grade fevers, low grade jaundice, borderline nutrition, and I was desperately trying to avoid an operative approach. ERCP was considered, but the guys I usually use have had only modest success with B2 ES (although excellent results otherwise). The radiologist (excellent) was unable to cannulate ducts because of borderline size. I therefore sent this pt more than 100 miles away to a superspecialist in Toronto who has had excellent B2 retrievals (scope within scope, contact lithotriptor, etc,etc). He got the stone out, pt back by ambulance 4 hrs later and within 24 hrs pt was a different man entirely. I guess the conclusion is to go the extra mile, so to speak. I guess I now owe Dr Greg Haber a bottle of vintage single malt for saving my mutton, even if he is a gastroenterologist.

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Doctor Green

Re: retained hepatic stone - Ärzteforum

Post#7 »

To this I would add a chronic "suppressive" antibiotic treatment ; say a low dose of tetracycline for a month, then switch over to another drug for a month and so on. It has been described to prevent cholangitis in susceptible cases who otherwise are inoperable.

Wired

Re: retained hepatic stone - Ärzteforum

Post#8 »

A difficult problem. Right now you have a nonseptic pt with a common duct stone and no fistula. I would attempt to canulate the ducts tranhepatically if they are dilated. Theh the tract can be dilated and the tstone can be crushed by what ever means you likw.

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