What is the Mayo protocol for managing bile duct or gallbladder conditions?

Mayo Protocol for Bile Duct and Gallbladder Management

The Mayo protocol for managing bile duct injuries and common bile duct stones involves choledochoduodenostomy as the original surgical approach, with modern management now emphasizing a comprehensive strategy that includes proper diagnosis, specialized surgical repair, and minimally invasive techniques to reduce morbidity and mortality. 1

Bile Duct Injury Management

Diagnosis and Initial Assessment

• Bile duct injury (BDI) is mainly iatrogenic, occurring most frequently during cholecystectomy, with laparoscopic cholecystectomy having 2-3 times higher incidence (0.4-0.6%) compared to open cholecystectomy (0.125-0.3%) 1
• Comprehensive preoperative workup is mandatory to identify at-risk conditions such as scleroatrophic cholecystitis and Mirizzi syndrome 1
• Liver function tests and trans-abdominal ultrasound scanning are recommended as initial diagnostic steps for suspected common bile duct stones 1

Prevention of Bile Duct Injury

• Critical View of Safety (CVS) technique is recommended over other approaches to minimize iatrogenic complications during laparoscopic cholecystectomy 1
• When CVS cannot be achieved, alternative techniques such as "fundus-first" approach or subtotal cholecystectomy should be considered 1
• Optimal timing for cholecystectomy in acute cholecystitis is within 48 hours and no more than 10 days from symptom appearance 1

Surgical Management of Bile Duct Injury

• Surgery remains the mainstay of treatment for BDI and traumatic bile duct stricture 1
• The definitive repair involves exposing the proximal and distal bile duct, anastomotic bile duct tissue preparation, and minimally invasive tissue anastomoses 1
• Successful management requires specialized experience and precise surgical skill, with referral to specialized centers recommended 1

Common Bile Duct Stone Management

Diagnostic Approach

• Liver function tests and abdominal ultrasonography are the initial diagnostic steps for suspected common bile duct stones 1
• For persistent clinical suspicion with insufficient evidence on ultrasonography, endoscopic ultrasonography or magnetic resonance cholangiopancreatography is recommended 2

Treatment Options

Endoscopic Management

• Biliary sphincterotomy and endoscopic stone extraction is recommended as the primary treatment for patients with CBDS post cholecystectomy 1
• For difficult stones, limited sphincterotomy combined with endoscopic papillary large-balloon dilation is recommended as first-line approach 2
• Cholangioscopy-guided electrohydraulic lithotripsy (EHL) or laser lithotripsy (LL) should be considered when other endoscopic treatment options fail 1
• Temporary biliary plastic stent placement is recommended for irretrievable biliary stones that warrant drainage 2

Surgical Management

• Laparoscopic bile duct exploration (LBDE) is an appropriate technique for CBDS removal during laparoscopic cholecystectomy, with efficacy comparable to perioperative ERCP 1
• Transcystic or transductal approaches can be used for LBDE, with the transductal approach allowing access to larger stones and the common hepatic duct 1
• Laparoscopic cholecystectomy is recommended within 2 weeks after ERCP for patients treated for choledocholithiasis to reduce conversion rate and risk of recurrent biliary events 2

Special Considerations

• For elderly patients (≥75 years), a wait-and-see strategy after successful endoscopic extraction of main bile duct stones may be appropriate, as recurrent biliary events occur in only about 11% of cases 3
• For patients with combined gallbladder and CBD stones, single-session laparoscopic management is as safe and effective as sequential ERCP followed by laparoscopic cholecystectomy 4
• Ursodiol may be used for gallstone dissolution in select patients, but complete dissolution does not occur in all patients and recurrence within 5 years has been observed in up to 50% of patients 5

Management Algorithm

1. Diagnosis: Liver function tests and abdominal ultrasound as initial tests 1
2. If CBDS confirmed:
   • For patients with cholangitis: Biliary drainage based on severity (severe: within 12 hours; moderate: within 48-72 hours; mild: elective) 2
   • For patients without cholangitis: Offer stone extraction to all fit patients 2
3. Treatment approach:
   • If expertise available: LBDE during laparoscopic cholecystectomy 6
   • If LBDE expertise not available: ERCP (preoperative or intraoperative) followed by laparoscopic cholecystectomy 6
   • For elderly/high-risk patients: Consider ERCP with sphincterotomy alone without cholecystectomy 3
4. For difficult stones: Use limited sphincterotomy with large balloon dilation or cholangioscopy-guided lithotripsy 1, 2
5. For irretrievable stones: Place temporary biliary plastic stent 2

Pitfalls and Caveats

• Only 1/3-1/2 of bile duct injuries are diagnosed intraoperatively, and more than 70% are initially repaired by surgeons who do not specialize in such repairs 1
• Even in high-volume centers, the incidence of stricture after repair surgery of BDI reaches 10-20% 1
• Delayed referral to specialist centers increases morbidity and mortality 1
• Non-definitive surgical exploration and inappropriate timing of definitive repair surgery are common pitfalls 1
• Biliary stenting as sole treatment for CBDS should be restricted to patients with limited life expectancy and/or prohibitive surgical risk 1