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35 Case on Complicated Retained Stones in the Common Bile Duct
https://t.me/med1917
new CT scan demonstrated multiple fl uid collections in Douglas’ pouch, subhepatic
right, and in the retroperitoneum. The next day, a relaparotomy was performed due
to clinical deterioration.
Peroperatively, leakage was found because of the choledochoduodenostomy, and
a T-tube was placed through the anastomosis, the abdominal cavity was rinsed, and
new drains placed. Post-operatively, subphrenic fl uid collections developed, which
were treated by percutaneous drainage. In addition, the patient developed a pancreatic fi stula, with an average production of 500 cc/day being conservatively treated
with somatostatine and total parenteral nutrition (TPN). Despite these measures the
patient showed progressive clinical deterioration and at the 6th postoperative day,
feces appeared through the subcostal incision. A new surgical intervention was performed, in which a fecal peritonitis was found caused by a colon perforation at the
level of hepatic fl exure. The perforated segment was resected and a deviating colostomy created. The wound was closed by means of a Vycril mesh. Patient was again
admitted to the intensive care department, mechanically ventilated, and broad spectrum antibiotics and TPN administered. She developed pneumonia as well as a
wound infection, treated by VAC therapy. She improved clinically and could be
transferred from the intensive care to the medium care. Six weeks after the last
operation, she could leave the hospital in a reasonable condition for a revalidation
center. Pancreatic fi stula closed some weeks later. Two years later, understandably,
the patient still refused a new operation to close the colostomy and for repair of
cicatricial hernia.
187
Second Patient
Diagnosis and Indication for Surgery
Our second patient is a 73-year-old man presenting with complaints of diarrhea,
abdominal bloating, and fever. Medical history included a Billroth-II resection for
benign ulcer, COPD, and an elaborate cardiac history consisting of paroxysmal
atrial fi brillation and myocardial infarction. Laboratory study showed an acute
phase reaction with an elevated white blood cell count and cholestasis. An abdominal ultrasound depicted diffuse gallbladder wall thickening, characteristic of an
acute cholecystitis with an impacted obstructing stone in the neck of the
gallbladder.
Operation Description
After consideration of the patient’s general medical condition, percutaneous transhepatic gallbladder drainage was considered to be the initial treatment of choice.
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Fig. 35.2 MRCP showing
recurrence CBD stone
G.M.P. Diepenhorst
Ultrasound-guided drainage yielded 30 cc of pus and the drain was left in place.
After the procedure, ultrasound and posteriorly cholangiography showed no signs
of leakage and the following days the drain production decreased. The patient was
discharged in good clinical condition with the drain in place and an elective laparoscopic cholecystectomy planned. Before operation, a new cholangiography in the
outpatient setting demonstrated a stone in the distal CBD with slightly dilated intrahepatic bile ducts. However, outfl ow of contrast to the CBD, intra-hepatic bile ducts,
as well as to the duodenum appeared to be adequate. In addition, imaging showed a
limited amount of contrast leakage, possibly alongside the course of the drain
(Fig. 35.2 ). The patient was readmitted to hospital and an attempted removal of the
residual CBD stone by ERCP was undertaken, unsuccessful in part due to technical
limitations after the BII resection.
Consequently, an open cholecystectomy with CBD exploration and intraoperative cholangiography was performed. Peroperative cholangiography after
removal of the gallbladder demonstrated the presence of a fi xed stone in the distal
CBD. After a Kocher maneuver an open exploration of the CBD allowed removal
of a single stone and placement of a T-drain. During exploration, it seemed that the
space between instruments and posterior aspect of the pancreas was very thin.
During intraoperative cholangioscopy, a perforation proximal of the papilla vater on
35 Case on Complicated Retained Stones in the Common Bile Duct
https://t.me/med1917
Illustration 35.1 In patients
who underwent multiple
ERCPs and sphincterotomies,
an open CBD exploration
will be high risk operation for
complications. Perforation at
the level of the papilla is of
diffi cult treatment. In the fi rst
patient a
choledochoduodenostomy
was the treatment of choice
and in the second a Whipple
procedure
the posterior side was identifi ed. Multiple attempts, fi rst by performing a biliodigestive anastomosis, and second, stenting the perforation, were unsuccessful
(Illustration 35.1 ). Therefore, a Whipple procedure was considered as only option
and consequently performed. Postoperative histological examination of the specimen demonstrated signs of a chronic pancreatitis without signs of malignancy.
189
Postoperative Course: Identifi cation and Treatment
of Complication
At day 10, patient demonstrated septic clinical deterioration with fecal and biliary
drain production and subsequently a relaparotomy was performed (Fig. 35.3 ). At
operation, fecal contamination was found coming from a necrotic segment of the
transverse colon near the hepatic fl exure, being resected and anastomosed.
Furthermore, the hepatico-jejunostomy showed a limited amount of anastomotic
leakage, being the right subhepatic space drained.
Postoperatively, bile leakage continued so that a PTC drain was placed. Hospital
stay was further complicated by development of pneumonia as well as pleural fl uid
collections on both sides. Gradually, the patient improved clinically with an expectant policy, antibiotic treatment, and enteral nutrition. Percutaneous drain production
decreased and could be removed several weeks later. Finally, the patient was discharged from the hospital with the PTC catheter in place. A month later a
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Fig. 35.3 CT scan showing
contrast leakage following
Whipple
G.M.P. Diepenhorst
transhepatic cholangiography demonstrated adequate contrast fl ow through the
hepatico-jejunostomy without signs of leakage after which the PTC stent was initially closed off and fi nally removed. On the outpatient clinic, the patient complained about the loss of an incisive tooth, probably occurred during intubation.
Orthodontist costs were reimbursed. Patient is doing well.
Discussion
In these two cases, retained stones in the CBD after multiple sphincterotomies lead
to elaborate clinical complications. Retained CBD stones remain a challenging
problem, and if controversy exists regarding ideal management, it is the opinion of
the surgeon that patient should be operated on.
Since the 1980s, ERCP followed by sphincterotomy has become the most
widely used method for imaging and treating CBD stones [ 1 ]. Magnetic reso-
nance cholangiopancreatography (MRCP) serves as a noninvasive and sensitive
test for detection of bile duct stones, but it is relatively expensive and provides no
option for therapy. Repeated endoscopic stone extraction by ERCP is an accepted
treatment modality and avoids surgery. However, this technique will only provide
temporary relief from primary duct stones and repeated endoscopic treatment will
be required. In a prospective study in patients undergoing repeated endoscopic
stone extractions, the mean number of endoscopies carried out per patient was 7.3
and failure to completely clear the duct occurred in 36.4 % of all endoscopies [ 2 ].
Current options in management of CBD and gallbladder stones are open cholecystectomy and CBD exploration; laparoscopic cholecystectomy and laparoscopic CBD exploration (LCBDE); endoscopic sphincterotomy (ES) and
35 Case on Complicated Retained Stones in the Common Bile Duct
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191
subsequent laparoscopic cholecystectomy; or laparoscopic cholecystectomy followed by ES [ 3 ].
A number of studies have directly compared endoscopic and surgical interventions in management of CBD stones. Four randomized trials have compared open
surgery and ES for the treatment of CBD stones, reporting a high success rate for
both procedures (90–95 %) without a signifi cant difference in morbidity and mortality but a longer hospital stay after surgery [ 4 ]. A trial comparing ES and surgery
in patients with severe cholangitis showed less morbidity (34 % vs. 66 %) and less
mortality (10 % vs. 32 %) associated with ES [ 5 ].
A number of trials have compared laparoscopic CBD exploration with ES as
treatment for CBD stones. One of these randomized studies shows laparoscopic
cholecystectomy plus laparoscopic CBD exploration and endoscopic retrograde
cholangiopancreatography sphincterotomy plus laparoscopic cholecystectomy to
be equivalent in effectiveness and cost, with shorter hospital stay after laparoscopic CBD exploration. Other trials confi rm these fi ndings, demonstrating laparoscopic CBD exploration and ES to be effective intervention strategies in detection
and removal of CBD stones, without signifi cant differences in complication or
mortality rates with a shorter hospital stay in the laparoscopic approach to CBD
exploration [ 6 ].
In summary, there is still an indication for open surgery if ES fails or if stones
cannot be removed endoscopically. As alternative for ERCP, laparoscopic CBD
exploration should be preferred for fi t patients (ASA I and II).
ES should be the management of choice for patients with severe cholangitis.
These two patients had gallstones and CBD stones. Traditional treatment will
consist of open or laparoscopic cholecystectomy and CBD exploration. As alternative for surgical CBD exploration, ERCP and papillotomy has been developed
in many countries as fi rst choice treatment, in order to clear the CBD stones
before laparoscopic cholecystectomy. Questions arises, how many attempts
should a gastroenterologist perform in the event the fi rst treatment is not successful and if the use of a stent should be considered safe to assure the free pass of
bile through the papilla. In elderly patients, the stent may be considered as alternative for operation. From the surgical point of view, it seems logical to perform
ERCP and papillotomy, one or two times, and, if not successful, to indicate a
cholecystectomy and CBD exploration. In the fi rst case, seven ERCPs with four
sphincterotomies were performed, and in the second case, four ERCPs and one
sphincterotomy.
It is imaginable that repeated papillotomies may cause covered perforation of the
papil and may alter the wall between papilla and posterior aspect of pancreas. This
problem may explain the complication in these two cases, the pancreas leakage in
the fi rst patient, and the perforation—in spite of proper technique—near the papilla
in the second. The other complication as found in both cases of the hepatic fl exure
perforation of the colon may be attributed to a technical complication during surgery, which should have been avoided.
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G.M.P. Diepenhorst
References
1. Barwood NT, Valinsky LJ, Hobbs MS, et al. Changing methods of imaging the common bile
duct in the laparoscopic cholecystectomy era in Western Australia: implications for surgical
practice. Ann Surg. 2002;235:41–50.
2. Kohn GP, Hassen AS, Banting SW, et al. Endoscopic management of recurrent primary bile
duct stones. ANZ J Surg. 2008;78:579–82.
3. Gouma DJ, Terpstra OT. Gallstone disease – surgical aspects. In: van Lanschot JJB, Gouma DJ,
Jansen PLM, Jones EA, Pinedo HM, Schouten WR, et al., editors. Integrated medical and sur-
gical gastroenterology. Houten: Bohn Stafl eu Van Loghum; 2004. p. 158–66.
4. Targarona EM, Ayuso RM, Bordas JM, et al. Randomised trial of endoscopic sphincterotomy
with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk
patients. Lancet. 1996;347:926–9.
5. Lai EC, Mok FP, Tan ES, et al. Endoscopic biliary drainage for severe acute cholangitis. N Engl
J Med. 1992;326:1582–6.
6. Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial
comparing two-stage vs single-stage management of patients with gallstone disease and ductal
calculi. Surg Endosc. 1999;13:952–7.
Chapter 36
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Case on Complications After ERCP
and Sphincterotomy
Miguel A. Cuesta
Keywords Papilla Vater perforation • ERCP • Sphincterotomy • Necrotizing acute
pancreatitis • Multiple organ failure (MOF)
First Patient
ERCP and Papillotomy and Acute Necrotizing Pancreatitis
Diagnosis and Indication for Surgery
A 29-year-old obese female patient known with immunosuppressive disease
underwent elsewhere an ERCP because of a suspicion for having CBD stones with
colics and alteration of liver enzymes. As consequence of the ERCP without papillotomy, she developed in the course of 2 days a necrotizing acute pancreatitis (CT
scan confi rmed) with multiple organ failure (MOF). Patient was intubated and
ventilated with a high PEEP of 14, and acute dialysis became necessary because of
the acute renal insuffi ciency. Due to her obesity (BMI 47), ventilation was becoming diffi cult and on a new CT scan important volumes of fl uids were seen in the
abdomen (Fig. 36.1 ) and clinically an abdominal compartment syndrome was
diagnosed.
M. A. Cuesta , M.D.
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_36,
© Springer International Publishing Switzerland 2014
193
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Fig. 36.1 CT scan showing
acute necrotizing pancreatitis
and huge fl uid collection
Operation
M.A. Cuesta
Consequently, surgeon performed a long transversal upper abdomen laparotomy in
order to decompress the abdomen and there a huge fl uid collection was drained.
Abdomen was left open and temporarily closed by means of a double Vicryl ® mesh.
Postoperative Course: Identifi cation and Treatment
of Complication
The next day feces appeared under the mesh, inspection revealed that the leakage
came from the colon, and a reoperation was planned. At relaparotomy, an opening
was found in the transverse colon near the splenic fl exure. Her upper abdomen was
changed as a plastron, and surgeon closed the colon distal of perforation by staples
and after dissection of the transverse mesentery, the surgeon could create a colostomy at the middle-right abdomen. Two drains were left, one along the colon and
the other in the pancreatic area. Abdomen was rinsed and closed temporarily by
means of a VAC system. On CT scan a retrogastric abscess was diagnosed and percutaneously drained (Fig.
wound started to granulate. Ventilation was diffi cult and a tracheotomy was given.
At the same time, the patient’s clinical condition improved, her renal function
recovered, and she could be extubated. Eight weeks after her admission to the
Intensive Care Unit, patient could go to a revalidation center. She did not wish the
36.2 ). Colostomy remained vital and productive and
36 Case on Complications After ERCP and Sphincterotomy
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Fig. 36.2 CT scan showing a
retrogastric abscess, being
percutaneously drained
VAC system for this period, which was feasible because the wound was smaller
with healthy granulating bottom. Local care by Polimem ® was applied to the surface
of the wound.
After a period of revalidation and having gained a BMI of 35 a year later, she
underwent a new operation to close the wound and the colostomy.
195
Second Patient
ERCP and Sphincterotomy and Papilla of Vater Perforation
Diagnosis and Indication for ERCP
A 64-year-old man underwent an ERCP and endoscopic papillary with large balloon dilatation because of cholelithiasis and CBD stone in the CBD. He had had
colics for 2 years and if not jaundiced cholestasis had been observed in the lab study.
At the ERCP a stone was removed through sphincterotomy by balloon and Dormia
catheter. Post-ERCP, patient had high fever and abdominal pain.
Postoperative Course: Identifi cation and Treatment
of Complication
The day after, a CT scan revealed retroperitoneal emphysema with fl uid collection
as sign of papilla of vater perforation (Fig. 36.3 ). The patient was treated by broad
spectrum antibiotics, nasogastric tube, and total parenteral nutrition (TPN). After
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Fig. 36.3 CT scan,
retroperitoneal emphysema,
and abscess
M.A. Cuesta
Fig. 36.4 CT scan showing
retroperitoneal abscess
percutaneously drained
referral, a new CT scan showed retroperitoneal abscess, being drained by CT-guided
percutaneous drainage (Fig.
36.4 ). Slowly the condition of the patient improved and
after 2 weeks the drain could be removed (Illustration 36.1 ). He was scheduled to
undergo a laparoscopic cholecystectomy.
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