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36 Case on Complications After ERCP and Sphincterotomy
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197
Leakage
Sphincterotomy
Illustration 36.1 After perforation of papilla of vater by sphincterotomy, this will be percutaneously drained
Discussion
Originally, the ERCP had been designed and used to assess the biliary duct, but
subsequently the possibility arose to intervene the papilla of vater by means of
sphincterotomy. A review of 119 patients who underwent an ERCP with or without
sphincterotomy in our department was carried out in a period when papillotomy
was extensively used for assessment of jaundice, acute pancreatitis, and for CBD
stones [ 1 ]. The study showed a high positive predictive value (over 85 %) for the
presence of CBD stones in patients with acute cholangitis, persistent obstructive
jaundice or in the acute phase of gallstone pancreatitis. The complication rate of
ERCP with sphincterotomy was 14 % with a mortality rate of 2 %. These results
argued for more selective use of preoperative ERCP to be used only for patients
with acute cholangitis, persistent jaundice or acute gallstone pancreatitis.
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M.A. Cuesta
Complications, such as perforation with retroperitoneal abscesses, bleeding, and
acute pancreatitis, were found to be frequent. Evidence-based studies and the introduction of MRCP has since decreased the numbers of unnecessary ERCP, especially
in normal-size CBD and consequently has reduced the morbidity. Indications are
stricter now and all involved have agreed that sphincterotomy should be done
selectively.
In the cases of CBD stones, there is also a possibility to dilate the papilla of vater
by means of balloon dilatation. Feng et al. did a meta-analysis of seven randomized
controlled trials, including 790 patients, which compared the sphincterotomy (EST)
with the balloon dilatation technique (EPLBD) [ 2 ]. The overall successful clearance
rates of bile duct stones (97.35 % vs. 96.35 %), stone clearance in the fi rst ERCP
session (87.87 % vs. 84.15 %), and removal of large-sized stones were comparable
between the two modalities. EPLBD was associated with fewer overall complications than EST (5.8 % vs. 13.1 %). Hemorrhage occurred less frequently with
EPLBD than with EST and there was no signifi cant difference in post-ERCP pancreatitis, perforation, and cholangitis. They concluded that EPLBD is an effective
and safe method for the removal of large or diffi cult common bile stones.
The complications presented in these two cases underscore how important it is to
establish a good indication for the ERCP and sphincterotomy.
References
1. Rijna H, Borgstein PJ, Meuwissen SG, et al. Selective preoperative ERCP in laparoscopic bili-
ary surgery. Br J Surg. 1995;82:1130–3.
2. Feng Y, Zhu H, Chen X, et al. Comparison of endoscopic papillary large balloon dilatation and
endoscopic sphincterotomy for retrieval of choledocholithiasis: a meta-analysis of randomized
controlled trials. J Gastroenterol. 2012;47:655–63.
Chapter 37
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Case on Lost Stones in Abdomen
After Laparoscopic Cholecystectomy
Miguel A. Cuesta
Keywords Lost Stones • Subphrenic abscess • Umbilical abscess • Laparoscopic
cholecystectomy
First Patient
Diagnosis and Indication for Surgery
A 44-year-old male patient was admitted in the hospital with the diagnosis of acute
cholecystitis, and a laparoscopic intervention was planned.
Operation
During intervention and after suction of the bile, stones fell into the abdominal cavity, being taken out in a bag as much as possible (Illustration 37.1 ). Moreover, the
cystic duct was wide and had to be stapled.
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_37,
© Springer International Publishing Switzerland 2014
199
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Illustration 37.1 Lost
stones during
cholecystectomy should be
removed completely.
Otherwise, the morbidity
caused is very high
M.A. Cuesta
Postoperative Course: Identifi cation and Treatment
of the Complication
Patient did well postoperatively but 3 weeks after operation he had fever and abdominal pain in the right upper abdomen and fl ank. Readmission followed and differential
diagnosis was made regarding problems with the integrity of CBD or retained stones.
A US showed some dilatation of the CBD, and on the ERCP no stones were detected,
and neither lesion of the CBD was seen. Because of persistent fever and pain, a CT
scan was performed, and here a subphrenic collection with gas and structures alike
stones were seen in the subphrenic and subhepatic areas (Figs. 37.1 and 37.2 ). A new
laparoscopic exploration was performed in which pus was drained from both spaces
and some stones were removed. After operation patient persisted having pain and
fever; he was impeded in going back to work as machinist at a construction company.
A new CT scan showed that the subfrenic abscess had not disappeared and on its
posterior aspect there was at least one retained stone. Moreover, stones were seen in
two other locations, that is, in the gallbladder region and probably in the pouch of
Morrison. In the meantime, patient walked stooped due to fl ank pain, and a new laparoscopic intervention was proposed with a high chance for conversion.
Conversion to laparotomy was necessary because the subhepatic region was not
accessible, being both abscesses drained and different stones removed. Recovery
37 Case on Lost Stones in Abdomen After Laparoscopic Cholecystectomy
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Fig. 37.1 CT scan showing
subhepatic lost stones in an
abscess
Fig. 37.2 CT scan, lost
stones in the lateral subfrenic
space
201
for the patient took another 6 months. After active physiotherapy and much patience,
patient fi nally reinitiated his work as machinist.
Second Patient
Diagnosis and Indication for Surgery
A 34-year-old female patient was operated electively because of gallstones by a
laparoscopic cholecystectomy. During operation an important leakage of small and
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large stones as well as bile into the abdomen occurred. Moreover, a bleeding coming from the gallbladder bed was diffi cult to control.
M.A. Cuesta
Postoperative Course: Identifi cation and Treatment
of the Complication
While patient initially recovered and was discharged, yet after a period of several
weeks she returned with pain in the right abdomen. On the US and the CT scan no
problems were detected and the surgeon tried to convince her that everything was
satisfactory . In the mean time, she was referred to the urologist because of an infection of the urinary tract. For the next 2 years, the patient continued to experience
chronic complaints and was not able to return to her previous occupation at a kindergarten. After some referrals for pain to outpatient clinic and physiotherapist, she
subsequently visited the gynecologist for pain in her lower abdomen. She was
examined by US for a possible cyst in the right ovary. By US and vaginal examination, a right ovary cyst with solid contents was diagnosed and patient was proposed
to undergo another intervention by laparoscopy with possible conversion to laparotomy. Hereafter, infl ammation was found around her right ovary fi xed to the bladder and proved diffi cult to mobilize. The gynecologist converted the operation to a
Pfannenstiel incision and at the location between the right adnexa of the uterus and
the bladder; several old gallstones were found and removed. The right ovary was
found normal and left untouched.
Third Patient
Postoperative Course: Identifi cation and Treatment
of the Complication
After undergoing an elective laparoscopic cholecystectomy in which some leakage
of bile and stones occurred, a 67-year-old patient recovered and was discharged.
After a period of 2 months, the umbilical scar became red and infl amed and the
surgeon drained it under local anesthesia. The wound then closed and patient felt
well for some time. Six months later, the patient was readmitted because of recurrent umbilical abscess. A CT scan was performed revealing a large abscess with a
large stone of about 2 cm (Fig.
in the rest of abdomen. Under anesthesia the scar was opened, and the pus and stone
removed. Wound again was closed by secondary intention and the patient recovered
defi nitely.
37.3 ). No other stones or fl uid collection were visible
37 Case on Lost Stones in Abdomen After Laparoscopic Cholecystectomy
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Fig. 37.3 CT scan,
subumbilical abscess, and
stone
Discussion
The lessons regarding these three patients are, fi rst, that during laparoscopic (or
open) cholecystectomy all lost stones in the abdomen should be removed. Second,
that in case of recurrence of complaints in the upper and right abdomen a CT scan
should be done [ 1 ]. The found stones should be located and removed. Spilled stones
located in the pouch of Morrison are diffi cult to fi nd. Finally, if the patient has problems with the spine while standing or walking, a lengthy physiotherapy should be
initiated in order to ensure the patient is able to return to an active life.
203
Reference
1. Loffeld RJ. The consequences of lost gallstones during laparoscopic cholecystectomy. Neth
J Med. 2006;64:364–6.
Chapter 38
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Case on Late Stenosis of Biliodigestive
Anastomosis with Cholangitis (After
Laparoscopic Cholecystectomy)
Miguel A. Cuesta and Chris J.J. Mulder
Keywords Balloon dilatation • Gallstones • Biliodigestive anastomosis •
Cholangitis • Laparoscopic cholecystectomy
Diagnosis and Indication for Surgery
A 32-year-old female patient, residing in another country, was referred to our
department by the gastroenterologist because of a complete stop in her common
hepatic duct.
Nine months before she had been operated on for symptomatic gallstones by
means of a laparoscopic cholecystectomy.
During laparoscopy, the surgeon diagnosed a CBD lesion and converted the
operation to subcostal laparotomy. His description of the operation reads that “a
total division of the CBD was seen, and after mobilization of the proximal CBD and
Kocher manoeuvre, an end-to-end anastomosis was performed with drainage of the
CBD by means of a T-tube.” Patient recovered well and the T-tube was removed 2
months later after certainty that there was no stenosis or dilatation and a good passage to duodenum. After a normal period of 6 months, the patient returned with
complaints and was admitted to the department of Gastroenterology because of
obstructive jaundice. On CT scan and ERCP a complete stop was seen in the CBD
at the level of hepatic duct (Fig. 38.1 ), so the patient was drained by means of a PTC
M. A. Cuesta , M.D. ()
Department of Surgery , VU University Medical Center , Amsterdam , The Netherlands
e-mail: ma.cuesta@vumc.nl
C. J.J. Mulder
Department of Gastroenterology , VU University Medical Center , Amsterdam ,
The Netherlands
M.A. Cuesta, H.J. Bonjer (eds.), Case Studies of Postoperative Complications
after Digestive Surgery, DOI 10.1007/978-3-319-01613-9_38,
© Springer International Publishing Switzerland 2014
205
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Fig. 38.1 CT scan, stop in
the CBD with intrahepatic
duct dilatation
Fig. 38.2 Operation view
hepaticojejunostomy
M.A. Cuesta and C.J.J. Mulder
drain introduced through the left hepatic duct, and an operation was planned for
reconstruction.
Operation
At operation, done through a subcostal incision, a biliodigestive anastomosis with
a Roux-en-Y anastomosis was performed (Fig. 38.2 , and Illustration 38.1 ). Patient
38 Case on Late Stenosis of Biliodigestive Anastomosis with Cholangitis
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did postoperatively well and could go home with the PTC drain after 10 days.
Six weeks later, a cholangiography showed a good patent anastomosis and the
PTC drain was removed.
Postoperative Course: Identifi cation and Treatment
of Complication
Eighteen months later she was again readmitted because of periods of acute cholangitis probably caused by stenosis of the bilio-digestive anastomosis. She was treated
initially with iv Antibioticss. On the PTC, a stenosis of anastomosis was found
(Fig. 38.3 ), which was consequently dilated by means of a balloon (Fig. 38.4a and
Illustration 38.1 ) with success. Patient is currently under control at the outpatient
clinic.
207
Illustration 38.1 Stenosis of a hepaticojejunostomy should be dilated through a PTC, if not possible a revision of the anastomosis should be performed
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