Stones are normally found in the Gall Bladder. A narrow vessel called Common Bile Duct connects the Liver to the gall bladder. Bile Juice from the Liver comes into the Gall Bladder through this duct. Stones can sometime get stuck in the common bile duct and block the flow of bile juice from the Liver to the Gall Bladder. This causes Jaundice and can result in great damage to the Liver. In such cases the Gastroenterologist removes the CBD stones using an Endoscope in a procedure called Endoscopic Retrograde Cholangio- Pancreatography (ERCP). In some cases if the stone cannot be removed then a stent is placed to bypass the blocked vessel and create a path for the flow of the bile juice. Normally the gastroenterologist breaks the stone in smaller pieces and extracts them. However if the CBD stone is stuck in such a manner that it cannot be removed through Endoscope then an open surgery is done from the front of the chest.
Patients presenting with CBDS have symptoms including biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic. There are several techniques to remove CBD stones and one of the most common technique is to do ERCP for CBD Stones.
ERCP as a diagnostic test has been mostly replaced by a non invasive test called MRCP. Magnetic resonance Cholangio Pancreatography (MRCP) is a technique for viewing the bile ducts and the pancreatic duct. It can also show the pancreas, gallbladder and liver. MRCP uses magnetic resonance imaging (MRI) to produce detailed pictures of these ducts and organs.
Most of the patients with CBD stones also have Gall Stones. In such cases the Gall Bladder is removed using a Laparoscope and the surgery is called Laparoscopic Cholecystectomy. In such cases the surgeon can also do Laparoscopic Common Bile Duct Exploration (LCBDE). In some cases the surgeon would do Laparoscopic Cholecystectomy and the Gastroenterologist would do ERCP in the same sitting. In other cases ERCP is done first to remove the CBD stones and Lap Chole is done after a few days. The gall stones is not such an emergency as the CBD stones are.
With advancing technology and minimally invasive surgery (laparoscopic biliary surgery) has become safe, efficient, and cost effective. Laparoscopic common bile duct exploration (LCBDE) is associated with successful stone clearance rates ranging from 85% to 95%.
If CBDS are detected at the time of laparoscopic cholecystectomy, the best treatment is a trans-cystic laparoscopic approach during the same operation. If this fails alternate approaches such as intraoperative or postoperative ERCP, laparoscopic choledochotomy, or open CBDE may be used . A trans-cystic approach is generally used for small stones in a small bile duct whereas trans-ductal approach is preferred for large occluding stones in a large duct, intrahepatic stones, or a miniscule or tortuous cystic duct. Most of the hospitals do not have the facility of a Gastroenterologist and an endoscope and therefore do not perform ERCP procedure even though they do Gall Stone Surgeries.
Patients with Gall Stones or CBD Stones normally undergo an Ultrasound examination which finds the presence of these stones. In cases of CBD Stones further testing in the form of MRCP is required. The cost for these investigations is around Rs. 8-10 thousand Indian Rupees. If Laparscopic Gall Bladder Surgery is required then the cost would be in the range of Rs. 60-70 thousand Rupees while the Cost for ERCP is Rs. 55-60 thousand depending upon whether a stent is used during the surgery or not. The hospital stay for ERCP is just one day while the stay would increase by another day if Lap Chole Surgery is done during the same sitting. Dr Sumita Singh and Dr Mayank Madaan are the best Laparoscopic Surgeons for doing the gall bladder surgery while Dr Anukalp Prakash is the best Gastroenterologist for doing ERCP.
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ERCP is best procedure for:
Check lasting belly pain or jaundice.
Find gallstones or diseases of the liver, bile ducts, or pancreas.
Remove stones from the common bile duct if they are causing problems. These may include a blockage (obstruction), inflammation or infection of the common bile duct (cholangitis), or pancreatitis.
Open a narrowed bile duct or insert a drain.
Get a tissue sample for further testing (biopsy).
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