2010年3月专题讲座-CBDS的处理策略.ppt

1、Common Bile Duct Stones- Management Options,解放军324医院肝胆外科 张丰深,Gallstones,Incidence 12% men and 24% women (from autopsy study in UK) 10-30% of gallstones will become symptomatic (1-2% per year) Incidence of CBD stones found before or during cholecystectomy 12%,Composition,Cholesterol (70-80%) Uncommon

2、ly pure cholesterol stones (10%) Most have calcium salts in their centre (90%) and 10% of these have enough calcium to be radioopaque Pigment (20-30%) BLACK-secondary stones associated with haemolysis or cirrhosis BROWN-primary stones associated with bile stasis or infection,Shojaiefard A, et al. Va

3、rious techniques for the surgical treatment of common bile duct stones: a Meta review. Gastroenterology Research and Practice, 2009; 1-12,Classification,Primary Stones (5%) Form de novo in CBD Related to biliary stasis and infection Tend to be brown pigment stones Secondary Stones (95%) Formed in ga

4、llbladder Tend to be cholesterol stones,Classification,Retained 2yrs post cholecystectomy,Presentation,Incidental findings at cholecystectomy Biliary colic Jaundice Pancreatitis Cholangitis,The 4 main liver enzymes 毛远丽, 刘志国, 孙志强, 等. 检验与临床诊断-肝病分册. 北京: 人民军医出版社, 2006:131-210,Risk stratification,Risk st

5、ratification,Initial classification of suspected choledocholithiasis according to Cotton criteria as determined by ERCP and MRCP (Calvo et al, Mayo Clin Proc, 2002),Risk Stratification,Predictive scores for each multivariate factor used to produce the scoring system (Menezes et al, BJS, 2002),Risk s

6、tratification,High risk if-CBD 6mm -2 or more abnormal LFTs -cholecystitis/pancreatitis ? Preoperative ERCP Intermediate risk-MRCP Low risk-USS then LC,Imaging,Plain x-ray Ultrasound CT MRCP ERCP,Ultrasound,Most widely used Easy to perform Causes little discomfort Avoid irradiation and contrast medi

7、a 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

8、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 i

9、maging of pancreas if suspicion of malignant disease and other abdominal organs,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 8

10、9% Accuracy 92%,MRCP,Advantages No irradiation Avoids complications of ERCP in 5%-10% of patients Disadvantages Claustrophobic primary closure +/- antegrade stent across ampulla; cystic duct tube decompresion,CBD decompression,Controversy over T-tube, antegrade stents, cystic duct stents or no drain

11、age If any doubts about free postoperative drainage of bile through ampulla, then decompress Most likely to need decompression if stone was impacted, extensive ampullary monipulation or cholangitis Subhepatic drainage essential,Reasons to consider conversion to open choledochotomy,Unsuccessful trans

12、cystic CBD exploration Unsuccessful laparoscopic CBD exploration Multiple CBD stones (10) Large CBD stones Intrahepatic or proximal duct stones Impacted stones Failed or unavailable ERCP,Open choledochotomy,Successful exploration involves an adequately sized choledochotomy to facilitate removal of s

13、tones and choledochoscopy Introduction of choledochoscopy (1970-80s) led to a decline in retained stones from 10% to 1.2% Choledochoscopy allows visualisation of several generations of upper ducts (when dilated) and the ampulla,T-tube,CBD decompression Allows access to biliary tree for postoperative

14、 cholangiography and reexploration without the need for reoperation,T-tube complications,Fluid and electrolyte disturbances Bile leak around T-tube Bile leak after removal 1%-19% Silicon coated latex tubes cause less fibrotic response than red rubber tubes, need to stay in longer (4-6weeks) to avoid

15、 biliary peritonitis on removal Advocated for complicated cases such as cholangitis, pancreatitis or difficult exploration In the absence of these factors primary closure has been shown to be as safe as T-tube drainage in several randomised trials (De Roover et al, Acta Chir Belg, 1989; Sheen-Chen a

16、nd Chou, Acta Chir Scand, 1990 1-12 -以ERCP为先导,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Liu

17、TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Group 2 patients,Group 1 patients,Group 3 patients,Group 4 patients,Therapeutic ERCP,MRCP,LC+IOC,LC,(),(),Liu TH, et al. Patient evaluation and management with selective use of MR

18、CP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-40,Liu TH, et al. Patient evaluation and management with selective use of MRCP and ERCP before LC. Ann Surg 2001; 234(1): 33-4

19、0,胆囊结石继发胆总管结石危险度分级 解放军第324医院肝胆外科,Gallbladder stones,Low suspicion of CBD stones,Intermediate Suspicion of CBD stones,high suspicion of CBD stones,LC,Lap-IOC,No CBD stones,CBD stones,MRCP,No CBDS,CBDS,Therapeutic ERCP,经胆囊管LCBDE,经胆总管切开LCBDE,Failure,解放军第324医院肝胆外科胆结石微创诊疗流程,Failure,Success,No suspicion o

20、f CBD stones,Management of CBDS depends on 总的趋势是无/微创、cost-effective 病人一般情况能否耐受麻醉和复杂操作; 胆囊有无结石/胆管病理/CBDS情况/胆胰肠接合部;病人意愿/经济情况;personal experience;equipment availability;time and the availability of other expertise.,后记GBS继发CBDS诊疗的EBM实践,一、GBSCBDS可能性的评估及存在的问题 二、何时继续试验？何时治疗？治疗方法选择？ 三、基于我们临床实践的GBSCBDS预测的方法、

21、进一步的诊疗流程完善,GBSCBDS可能性的评估及存在的问题,灵敏度sen=真阳性率TP=a/(a+c) 特异度spe=真阴性率=d/(b+d) 假阳性率FP=误诊率=b/(b+d) =1-spe 假阴性率FN=漏诊率=c/(a+c)=1-sen 患病率pre=(a+c)/N 正确性acc=粗符合率=(a+d)/N 正确性指标=Youdens index =(sen+spe)-100% 值= 2(ad-bs)(a+b)(c+d)(a+c)(b+d ) 0.711.00 很好 0.400.74 一般 0.010.39 不好,GBSCBDS可能性的评估及存在的问题,阳性预测值PV=a/(a+b)

22、PV pre sen pre sen(1spe)（1 pre ） 阴性预测值PV=d/(c+d) PV spe（1 pre ） spe（1 pre ） sen （1 pre ） 阳性似然比LR+ = a/(a+c) b/(b+d)= sen/(1-spe) 阴性似然比LR- = c/(a+c) d/(b+d)= (1-sen)/spe,GBSCBDS可能性的评估及存在的问题,连续计量资料的分界值及其对诊断试验评价指标的影响： 1、正常值，截断值（cut-off value），根据不同需要设定的阈值（threshold）。 2、选择不同的分界值，可得出不同的sen、spe、其他评价指标也随之改变

23、。 3、 sen和spe是两个属性完全不同的指标，理想的是两者都非常高，但实际情况是不可兼得、两者相互制约： 目的是是筛查、初步诊断和排出诊断，强调高sen的试验； 因漏诊而延误诊断、会失去最佳治疗时机而造成严重后果，也强调高sen的试验；目的是确诊时应强调spe； 误诊会导致严重经济负担，甚至因不当诊疗出现并发症或毒副作用，也应强调spe。,GBSCBDS可能性的评估及存在的问题,GBSCBDS可能性的评估及存在的问题,连续计量资料的分界值确定一般以兼顾sen和spe的cut-off 值。 以受试者工作特性曲线（ROC曲线）拐点处为截断值，即sen和spe均较高的点。 Clinical ra

24、nges of Sen and Spe: both50%,1.0cm,250,PV问题 PV pre sen pre sen(1spe)（1 pre ） PV spe（1 pre ） spe（1 pre ） sen （1 pre ）,GBSCBDS可能性的评估及存在的问题,“sen是疾病阳性、spe是健康阴性”。 100sen与100PV-相对应（排出）；100spe与100PV+相对应（纳入）；当sen和spe不等于100时，PV依赖于疾病的患病率（验前概率） 、且需逐个计算。 “高sen阴性结果可排出疾病（SnNout）、高spe阳性结果可诊断疾病（SpPin）”Sackett DL,LR

25、问题 阳性似然比LR+ = a/(a+c) b/(b+d)= sen/(1-spe) 阴性似然比LR- = c/(a+c) d/(b+d)= (1-sen)/spe LR的含义：试验结果使验前概率（患病率pre）提高或降低的多少。不受患病率的影响。在临床实践中得粗略原则： LR+ or LR- 10 0.1 使验前概率到验后概率发生决定性变化，基本可确定or排出诊断 5-10 0.1-0.2 中等度变化 2-5 0.2-0.5 较小程度变化 1-2 0.5-1 基本不变化 根据试验前病人的患病率（验前概率）和某项试验的LR，可以按Bayes条件概率公式得出验后概率，但须换成比数（odds）来计

26、算、然后再转换为概率：验前比=验前概率/(1-验前概率) 验后比=验前比LR 验后概率=验后比/（1验后比）,GBSCBDS可能性的评估及存在的问题,GBSCBDS可能性的评估及存在的问题,1、10%-20%的symptomatic GBS继发CBDS。Retained CBDS有潜在的威胁生命的并发症：AC、SAP或使MAP重型化。so，急诊取出正在梗阻的结石（symptomatic CBDS）、及时的取出松动的结石（resolving CBDS）。 2、indicators：clinical：history of 胆管炎、黄疸and胰腺炎, symptomatic CBDS 、presen

27、t 黄疸and胰腺炎；serum chemistries：ALT、AST、TB、DB、ALP、GGT、AMS；CBDS on US、CBD dilatation on US。（15项） 3、The natural history of CBDS is largely unknown： the rates at which gallstones pass from the gallbladder? how long stones reside in the CBD? CBDS may pass from CBD into duodenum either with/without symptoms

28、 or other evidence of cholestasis. 4、No single indicator is completely accurate in predicting CBDS before cholecystectomy.,GBSCBDS可能性的评估及存在的问题,4、The performance characteristics of each indicator：由于分界值的选择不明确、评判标准不同、应用目的有差异、等，各预测指标的差异大、适用状况不清、有的指标的诊断特性无报道。 5、The constellation of indicators : to conden

29、se them into a formula is extremely difficult ,even using multivariate analysis。The established decision rules：多，适用不明确 、不便，相互矛盾。 6、GBS继发CBDS的诊疗策略：尚无一致性的流程？EBM有望解决此难题？,GBSCBDS可能性的评估及存在的问题,何时继续试验？何时治疗？治疗方法选择？,试验原则：应用可能改变处理方案的试验。 治疗原则：选用好处多于坏处的治疗方案。 行动阈值(action threshold, AT)：在患病可能性达到时、您会采取治疗，即此时治疗益处大于

30、害处？,何时继续试验？何时治疗？治疗方法选择？,治疗益处(B)=30 治疗害处(H)=10 AT odds=H/B=x AT ratio=x/(1+x) 诊断阈值=AT odds/LR+ 转化为率 治疗阈值=AT odds/LR- 转化为率 患病率治疗阈值：不试验而直接治疗 诊断阈值 治疗阈值、需治疗,何时继续试验？何时治疗？治疗方法选择？,何时继续试验？何时治疗？治疗方法选择？,CBDS急性并发症估计(Gastroenterol Res and Prac 2009; 1-12)： 有症状GBS继发CBDS以10估计。 Symptomatic CBDS仅保守治疗90可好转，10死亡。 急性胆源

31、性胰腺炎90仅保守治疗可好转，10死亡。,治疗益处(B)=8 治疗害处(H)=1 AT odds=H/B=1/8 AT ratio=1/9=11%,何时继续试验？何时治疗？治疗方法选择？,何时继续试验？何时治疗？治疗方法选择？,1、如患者有AOC，如何决策？ 验前概率=10% 验前比=0.1(1-0.1)=1/9 AOC的LR+=18.3=18 LR-=0.9 验后比=验前比LR+=1/918=0.5 验后概率=0.5(1+0.5)=66% 诊断阈值=1/818=1/144 转化为率=1/145 治疗阈值=1/80.9=1/7.2 转化为率=1/8.2=12% 患病率(66%) 诊断阈值(1/

32、145) 患病率(66%) 12%：不再继续做试验而直接取石治疗（ERCP）,何时继续试验？何时治疗？治疗方法选择？,2、dilated CBD on US时，如何决策？ 验前概率=10% 验前比=0.1(1-0.1)=1/9 LR+=6.9=7 LR-=0.77=0.8 验后比=验前比LR+=1/97=7/9 验后概率=7/9(1+7/9)=44% 诊断阈值=1/87=1/56 转化为率=1/57 治疗阈值=1/80.8=1/6.4 转化为率=1/7.4=13.5% 患病率(44%) 诊断阈值(1/57) 患病率(44%) 13.5%：不再继续做试验而直接取石治疗（ERCP）？太高的阴性取石

33、率！,何时继续试验？何时治疗？治疗方法选择？,何时继续试验？何时治疗？治疗方法选择？,GBS with suspected CBDS 诊疗策略拟订的依据： 以临床表现、血肝功生化和经腹B超为预测GBS with suspected CBDS 可能性大小（验后概率）的指标，验前概率10-20%。 本单位微创诊疗的手段：therapeutic ERCP、MRCP、IOC、LC、LC+LCBDE; 兼顾Lap-Chole术前和术中诊疗率、尽量提高术前诊疗率； 考虑MRCP费用、合理利用资源，控制阴性MRCP率、合理使用MRCP； 考虑ERCP的不适和并发症，尽量减少阴性ERCP。 考虑上述依据，参照

34、上表和参考AGSE(美国胃肠内镜协会2001)：？ High risk60% 肯定诊断 治疗性ERCP Intermediate risk30%60% 中度可能 MRCP Low risk30% 不能确定 Laparoscopic IOC,何时继续试验？何时治疗？治疗方法选择？,假定仅以AOC (symptomatic CBDS)、dilated CBD on US、TB、 ALP为CBDS的预测指标。 1、如患者有AOC（其他指标此时一般均为阳性），CBDS的可能性有多大？ 验前概率=15% 验前比=0.15(1-0.15)=15/85 AOC的LR+=18.3=18 验后比=验前比LR+=

35、15/8518=3.18 验后概率=3.18(1+3.18)=76% 60% 肯定诊断，治疗性ERCP,何时继续试验？何时治疗？治疗方法选择？,2、 无AOC，dilated CBD on US、TB升高、 ALP升高时， CBDS的可能性有多大？ 验前概率=15% 验前比=0.15(1-0.15)=15/85 LR=0.93 6.9 4.8 2.6=80 验后比=验前比LR=15/8580=14 验后概率=14(1+14)=93% 60% 肯定诊断，治疗性ERCP,何时继续试验？何时治疗？治疗方法选择？,3、 无AOC、无dilated CBD on US，TB升高、 ALP升高时， CBD

36、S的可能性有多大？ 验前概率=15% 验前比=0.15(1-0.15)=15/85 LR=0.93 0.77 4.8 2.6=8.9 验后比=验前比LR=15/858.9=1.57 验后概率=1.57(1+1.57)=61%60% 肯定诊断？治疗性ERCP？,何时继续试验？何时治疗？治疗方法选择？,4、 无AOC、无dilated CBD on US，TB升高，ALP正常时， CBDS的可能性有多大？ 验前概率=15% 验前比=0.15(1-0.15)=15/85 LR=0.93 0.77 4.8 0.65=2.2 验后比=验前比LR=15/852.2=0.39 验后概率=0.39(1+0.39)=28%30% 不能确定？LC+IOC？,何时继续试验？何时治疗？治疗方法