choledocholithiasis due to retained cystic duct stump: a ... · choledocholithiasis due to retained...
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Choledocholithiasis due to Retained Cystic Duct Stump:
A Novel Minimally Invasive Approach Eric Klein, MD
SUNY Downstate Department of Surgery
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Chief Complaint
• xx year old male directly admitted from surgeon’s office on dd/mm/yyyy with dehydration
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Relevant PMH / PSH
• Open cholecystectomy • Acute cholangitis • ERCP for acute cholangitis • Laparoscopic CBD exploration
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HPI
• Increased T-tube output (>500 ml / day) • Poor appetite • Postprandial pain
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Other PMH / PSH
• HTN • DM • CAD s/p CABG (2005) • Prostate cancer s/p radiation and
hormonal therapy
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Physical Exam • Temp - 97.0 • BP - 108/58 • HR - 70 • Alert and oriented • No jaundice • Poor skin turgor • Dry mucous membranes • T-tube filled with bile • JP drain empty
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Labs
• BUN – 104 • Creatinine – 3.6 • Total bilirubin – 2.3 • Lipase – 1772 • Albumin – 2.8
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T-tube cholangiogram (12/27/2011)
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T-tube cholangiogram (1/5/2012)
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Pre-op Course
• Acute kidney injury resolved with intravenous hydration
• Hematuria from traumatic Foley catheter insertion (2/1/2012) – Continuous bladder irrigation – Prostate fulguration
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Surgery (2/10/2012) • Combined ERCP / percutaneous CBD
exploration • Failed sphincterotomy due to duodenal
diverticulum • Choledochoscopy • Laser lithotripsy of CBD stones with holmium
laser • Balloon sphincteroplasty (8 mm) • T-tube (Council tip Foley catheter) replaced • Completion T-tube cholangiogram
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Post-op Course
• POD#3 – Bile leak into JP drain • POD#4 – T-tube cholangiogram revealing
T-tube (Foley catheter) migrated into duodenum
• POD#7 – Discharged home
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Choledocholithiasis
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Diagnosis
• CT scan • MRCP • Transabdominal ultrasound • Endoscopic ultrasound • ERCP • Intraoperative cholangiogram • Choledochoscopy • PTC
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Endoscopic Treatment (ERCP)
• Extraction – Balloon – Basket
• Lithotripsy – Mechanical – Electrohydraulic – Laser
• EBS (endoscopic biliary sphincterotomy) • EBD (endoscopic balloon dilation)
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Percutaneous Treatment
• Similar to endoscopic treatment
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Surgical Treatment
• Common bile duct exploration – Trancystic – Choledochotomy
• Sphincterotomy • Transduodenal sphincteroplasty • Cholecysto-jejunostomy • Choledocho-duodenostomy • Choledocho-jejunostomy
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Non-invasive Treatment
• Extracorporeal shock wave lithotripsy
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Post-cholecystectomy Syndrome
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Success of Cholecystectomy
• Gallbladders with stones (n = 170) – 152 (89.4%) complete symptomatic relief – 15 (8.8%) partial symptomatic relief – 3 (1.8%) total failures
• Non-calculous gallbladders (n = 47) – 36 (76.6%) complete symtomatic relief – 7 (14.9%) partial symptomatic relief – 4 (8.5%) total failures
Whipple AO. The Surgical Criteria for Cholecystectomy. Bull N Y Acad Med. 1926 June; 2(6): 302–306.
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Criteria for Cholecystectomy • A satisfactory account of one or more attacks of biliary
colic • Residual tenderness in the region of the gallbladder
following such episodes • Indigestion, which is usually characterized by flatulence,
bloating and discomfort • A positive cholecystogram giving evidence of a
nonfunctioning gallbladder or stones • Reasonably exact exclusion of conditions that simulate
cholecystitis
Weir, J. F., and Snell, A. M.: Symptoms That Persist After Cholecystectomy: Their Nature and Probable Significance, JAMA 105:1093-1098 (Oct. 5) 1935.
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Criteria for Cholecystectomy
“When such symptoms are presented by a stable, sensible individual who is not given to habitual complaining, good results almost certainly can be assured.”
Weir, J. F., and Snell, A. M.: Symptoms That Persist After Cholecystectomy: Their Nature and Probable Significance, JAMA 105:1093-1098 (Oct. 5) 1935.
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Vague Symptoms and Evidence of Gallbladder Disease on Cholecystography
Weir, J. F., and Snell, A. M.: Symptoms That Persist After Cholecystectomy: Their Nature and Probable Significance, JAMA 105:1093-1098 (Oct. 5) 1935.
1) Those presenting signs of constitutional inadequacy, with or without the mild grades of affective disorders
2) Migrainous individuals, with or without abdominal equivalents
3) Patients with the more severe degrees of the syndromes of so-called irritable colon
4) Those with lowered basal metabolic rates
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Causes of the Postcholecystectomy Syndrome • (other than incorrect initial diagnosis) • Mechanical irritation or obstruction of the
common bile duct because of stone or cystic duct remnant
• Functional spasm and incoordination (biliary dyskinesia) of the sphincter of Oddi
• Gastritis from bile reflux • Diarrhea from increased bile flow
McClenahan JE, Evans JA, Braunstein PW. Intravenous cholangiography in the post cholecystectomy syndrome. JAMA. 1955;159:1353.
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Removal of the Enlarged Remnant Cystic Duct
• Most patients also had CBD drained
• Stone in cystic duct stump (n = 7) – 83% successful (excluding 1 lost to follow-up)
• Stone in the CBD (n = 11) – 60% successful (excluding 1 lost to follow-up)
• No calculi present (n = 26) – 46% successful (excluding 1 lost to follow-up)
Gray HK, Sharpe WS. Biliary dyskinesia: role played by remnant of cystic duct. Mayo Clinic. 1944;19:164-8.
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Laser Lithotripsy
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Ell C, Lux G, Hochberger J, Müller D, Demling L. Laserlithotripsy of common bile duct stones. Gut. 1988 Jun;29(6):746–751.
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