Laparoscopic cholecystectomy and Trans-Cystic lithotripsy enable complete clearance of large Bile Duct stones using SpyGlass™ Discover with lithotripsy.
EAES Academy. Zino S. 07/05/22; 363029; P073
Abstract
Aims:
Laparoscopic cholecystectomy and bile duct exploration remain the gold standard treatment for gallstone disease that is associated with bile duct stone. Two sessions management with ERCP then laparoscopic cholecystectomy, subject patients to preventable risk of perforation, bleeding, and pancreatitis, especially if patient is fit and keen for cholecystectomy. Trans-Cystic bile duct exploration (TC BDE) appears to have less morbidity than Trans- Ductal BDE (TD BDE). However large BD stones remains the main challenges for Trans-Cystic approach along with inappropriate anatomy. We aim in this abstract to present a complex case of 48y old female with gall stones and large BD stones.
Results:
We present a case of 48 year old female with symptomatic gallstone and bile duct stones disease. Patient had previous open right nephrectomy that was complicated with abdominal abscess 17 years ago. Patient had failed ERCP despite Needle-knife papillotomy due to Large mobile and hard papilla. Unfortunately, patient had post ECRP pancreatitis that was complicated with abdominal collection around the head of the pancreases. Collection required radiologically drainage through the anterior abdominal wall, 13 days post pancreatitis. Patient recovered well and consulted for laparoscopic cholecystectomy and BD exploration with high risk of conversion to open. Procedure was planned 6 weeks after discharge. Laparoscopic cholecystectomy was difficult due to adhesions and shrunken gallbladder (Nassar grade IV). Trans-Cystic BDE was performed using basket inside catheter (BIC) technique. SpyGlass™ Discover choledochoscopy showed clear distal CBD and large 12mm stone in the common hepatic duct. Stone was also very hard and needed high setting of lithotripsy(30, Max). Stone was fragmented successfully and all fragments were extracted using baskets. Cystic duct was suture closed using 3.0 vicryl and two Robinson abdominal drains were left in the abdomen; one in Morrison’s pouch and one in the sub-diaphragmatic space. Patient has uncomplicated post-operative recovery and was discharged home after 5 days. 8 months follow up satisfactory.
Conclusion:
Trans-Cystic BD exploration has become safe and feasible even for large bile duct stone with the new technology. ERCP should be avoided in young fit patient especially females as they carry higher risk of post ERCP pancreatitis
Laparoscopic cholecystectomy and bile duct exploration remain the gold standard treatment for gallstone disease that is associated with bile duct stone. Two sessions management with ERCP then laparoscopic cholecystectomy, subject patients to preventable risk of perforation, bleeding, and pancreatitis, especially if patient is fit and keen for cholecystectomy. Trans-Cystic bile duct exploration (TC BDE) appears to have less morbidity than Trans- Ductal BDE (TD BDE). However large BD stones remains the main challenges for Trans-Cystic approach along with inappropriate anatomy. We aim in this abstract to present a complex case of 48y old female with gall stones and large BD stones.
Results:
We present a case of 48 year old female with symptomatic gallstone and bile duct stones disease. Patient had previous open right nephrectomy that was complicated with abdominal abscess 17 years ago. Patient had failed ERCP despite Needle-knife papillotomy due to Large mobile and hard papilla. Unfortunately, patient had post ECRP pancreatitis that was complicated with abdominal collection around the head of the pancreases. Collection required radiologically drainage through the anterior abdominal wall, 13 days post pancreatitis. Patient recovered well and consulted for laparoscopic cholecystectomy and BD exploration with high risk of conversion to open. Procedure was planned 6 weeks after discharge. Laparoscopic cholecystectomy was difficult due to adhesions and shrunken gallbladder (Nassar grade IV). Trans-Cystic BDE was performed using basket inside catheter (BIC) technique. SpyGlass™ Discover choledochoscopy showed clear distal CBD and large 12mm stone in the common hepatic duct. Stone was also very hard and needed high setting of lithotripsy(30, Max). Stone was fragmented successfully and all fragments were extracted using baskets. Cystic duct was suture closed using 3.0 vicryl and two Robinson abdominal drains were left in the abdomen; one in Morrison’s pouch and one in the sub-diaphragmatic space. Patient has uncomplicated post-operative recovery and was discharged home after 5 days. 8 months follow up satisfactory.
Conclusion:
Trans-Cystic BD exploration has become safe and feasible even for large bile duct stone with the new technology. ERCP should be avoided in young fit patient especially females as they carry higher risk of post ERCP pancreatitis
Aims:
Laparoscopic cholecystectomy and bile duct exploration remain the gold standard treatment for gallstone disease that is associated with bile duct stone. Two sessions management with ERCP then laparoscopic cholecystectomy, subject patients to preventable risk of perforation, bleeding, and pancreatitis, especially if patient is fit and keen for cholecystectomy. Trans-Cystic bile duct exploration (TC BDE) appears to have less morbidity than Trans- Ductal BDE (TD BDE). However large BD stones remains the main challenges for Trans-Cystic approach along with inappropriate anatomy. We aim in this abstract to present a complex case of 48y old female with gall stones and large BD stones.
Results:
We present a case of 48 year old female with symptomatic gallstone and bile duct stones disease. Patient had previous open right nephrectomy that was complicated with abdominal abscess 17 years ago. Patient had failed ERCP despite Needle-knife papillotomy due to Large mobile and hard papilla. Unfortunately, patient had post ECRP pancreatitis that was complicated with abdominal collection around the head of the pancreases. Collection required radiologically drainage through the anterior abdominal wall, 13 days post pancreatitis. Patient recovered well and consulted for laparoscopic cholecystectomy and BD exploration with high risk of conversion to open. Procedure was planned 6 weeks after discharge. Laparoscopic cholecystectomy was difficult due to adhesions and shrunken gallbladder (Nassar grade IV). Trans-Cystic BDE was performed using basket inside catheter (BIC) technique. SpyGlass™ Discover choledochoscopy showed clear distal CBD and large 12mm stone in the common hepatic duct. Stone was also very hard and needed high setting of lithotripsy(30, Max). Stone was fragmented successfully and all fragments were extracted using baskets. Cystic duct was suture closed using 3.0 vicryl and two Robinson abdominal drains were left in the abdomen; one in Morrison’s pouch and one in the sub-diaphragmatic space. Patient has uncomplicated post-operative recovery and was discharged home after 5 days. 8 months follow up satisfactory.
Conclusion:
Trans-Cystic BD exploration has become safe and feasible even for large bile duct stone with the new technology. ERCP should be avoided in young fit patient especially females as they carry higher risk of post ERCP pancreatitis
Laparoscopic cholecystectomy and bile duct exploration remain the gold standard treatment for gallstone disease that is associated with bile duct stone. Two sessions management with ERCP then laparoscopic cholecystectomy, subject patients to preventable risk of perforation, bleeding, and pancreatitis, especially if patient is fit and keen for cholecystectomy. Trans-Cystic bile duct exploration (TC BDE) appears to have less morbidity than Trans- Ductal BDE (TD BDE). However large BD stones remains the main challenges for Trans-Cystic approach along with inappropriate anatomy. We aim in this abstract to present a complex case of 48y old female with gall stones and large BD stones.
Results:
We present a case of 48 year old female with symptomatic gallstone and bile duct stones disease. Patient had previous open right nephrectomy that was complicated with abdominal abscess 17 years ago. Patient had failed ERCP despite Needle-knife papillotomy due to Large mobile and hard papilla. Unfortunately, patient had post ECRP pancreatitis that was complicated with abdominal collection around the head of the pancreases. Collection required radiologically drainage through the anterior abdominal wall, 13 days post pancreatitis. Patient recovered well and consulted for laparoscopic cholecystectomy and BD exploration with high risk of conversion to open. Procedure was planned 6 weeks after discharge. Laparoscopic cholecystectomy was difficult due to adhesions and shrunken gallbladder (Nassar grade IV). Trans-Cystic BDE was performed using basket inside catheter (BIC) technique. SpyGlass™ Discover choledochoscopy showed clear distal CBD and large 12mm stone in the common hepatic duct. Stone was also very hard and needed high setting of lithotripsy(30, Max). Stone was fragmented successfully and all fragments were extracted using baskets. Cystic duct was suture closed using 3.0 vicryl and two Robinson abdominal drains were left in the abdomen; one in Morrison’s pouch and one in the sub-diaphragmatic space. Patient has uncomplicated post-operative recovery and was discharged home after 5 days. 8 months follow up satisfactory.
Conclusion:
Trans-Cystic BD exploration has become safe and feasible even for large bile duct stone with the new technology. ERCP should be avoided in young fit patient especially females as they carry higher risk of post ERCP pancreatitis
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