Laparoscopic Common Bile Duct Exploration for Common Bile Duct Stones Complicated with Cholangitis in Patients with Roux
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LETTER TO THE EDITOR
Laparoscopic Common Bile Duct Exploration for Common Bile Duct Stones Complicated with Cholangitis in Patients with Roux-en-Y Gastric Bypass—Clinical Experience from Three Cases Maria Olausson 1 & Mikkel Westen 1 & Astrid E. B. Boilesen 1 & Daniel M. Shabanzadeh 1 Received: 14 August 2020 / Revised: 18 August 2020 / Accepted: 18 August 2020 # Springer Science+Business Media, LLC, part of Springer Nature 2020
Introduction
Cases
Laparoscopic Roux-en-Y gastric bypass (LRYGB) is a common elective bariatric surgery performed for morbid obesity. Due to a rapid weight loss after LRYGB, these patients have a high risk of common bile duct stones (CBDS) [1]. The CBDS course may be complicated by cholangitis. Gold standard treatment for CBDS is endoscopic retrograde cholangiopancreaticography (ERCP) with stone extraction and subsequent laparoscopic cholecystectomy as a two-stage procedure [2]. Due to the alternated anatomy after LRYGB, stone extraction through conventional ERCP cannot be performed and alternative techniques may include percutaneous transhepatic biliary drainage (PTCD), percutaneous or laparoscopic transgastric ERCP (LTG-ERCP), and transenteric ERCP [3]. A number of studies report successful treatment with laparoscopic common bile duct exploration (LCBDE) and cholecystectomy (LC) performed as a single-stage procedure in patients with CBDS and with native anatomy [4]. To our knowledge, no experiences of LCBDE + LC in RYGB patients with CBDS complicated by cholangitis have been reported yet. We present the clinical course of three patients with previous LRYGB admitted to our department with CBDS complicated with cholangitis and treated with LCBDE + LC. Severity of cholangitis was graded according to criteria from Tokyo Guidelines 2018 [5]. Laparoscopic port placement was performed according to the French technique and LCBDE through the transcystic approach. All procedures were performed by the same consultant surgeon (MW).
Case 1
* Daniel M. Shabanzadeh [email protected] 1
Department of Gastroenterology, Surgical Unit, Copenhagen University Hospital Hvidovre, Hvidovre, Denmark
A 66-year-old female with a medical history including atrial fibrillation, hyperthyroidism, chronic pain, laparoscopic appendectomy, and bilateral knee alloplastic. LRYGB was done 8 years prior to admission. The patient presented with diffuse abdominal pain throughout a week, nausea, and pale colored stools. Vitals included pulse (P) 118 and temperature (TP) 39.9 °C with normal blood pressure (BP) and respiration frequency (RF). Blood tests showed WBC 17.3 × 10^9/L, CRP 220 mg/L, ALP 808 U/L, bilirubin 75 μmol/L, ALT 430 U/L, amylase 172 U/L. Computed tomography of the abdomen revealed intra- and extra-hepatic cholestasis with a suspicion of a 5 mm CBDS. The severity of the cholangitis was a grade II. LCBDE and preoperative cholangiography showed several small stones in CBD with the largest being 4 mm. Stones were extracted and LC was performed with an uncomplicated postoperative course.
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