{"id":52015,"date":"2023-09-30T10:02:21","date_gmt":"2023-09-30T10:02:21","guid":{"rendered":"https:\/\/biomedpharmajournal.org\/?p=52015"},"modified":"2023-10-07T12:06:11","modified_gmt":"2023-10-07T12:06:11","slug":"large-element-de-novo-choledocholithiasis-a-case-report","status":"publish","type":"post","link":"https:\/\/biomedpharmajournal.org\/staging\/vol16no3\/large-element-de-novo-choledocholithiasis-a-case-report\/","title":{"rendered":"Large Element De Novo Choledocholithiasis: A Case Report"},"content":{"rendered":"\n

Introduction<\/strong><\/p>\n\n\n\n

Choledocholithiasis\nis defined by the presence of stones in the main bile duct. It is classified as\nprimary (85%) or secondary, according to the etiology of the stone. The prevalence of choledocholithiasis in patients with lithiasic\ncholecystitis reported in the American Society for Gastrointestinal Endoscopy\n(ASGE) and European Society for Gastrointestinal Endoscopy (ESGE) guidelines is\n8% to 18% 1,2<\/sup>. In Mexico, the proportion is 5% to 10% 3<\/sup>.<\/p>\n\n\n\n

Primary\ncholedocholithiasis is defined by the criteria of Saharia et al. 4<\/sup>,\nwhich consists of previous cholecystectomy, absence of signs of bile duct\nobstruction for two years, presence of an ovoid, soft, or friable calculus, and\nno long remnant of the cystic duct. The average time for the appearance of\nprimary cholelithiasis after cholecystectomy is between 8 and 12 years 5<\/sup>.<\/p>\n\n\n\n

Within the classification of gallstones, there is a precise\ndefinition for stones that are difficult to manage with criteria such as\ndiameter greater than 15 mm, stone impaction, and periampullary diverticulum,\nwhich influence the difficulty and therapeutic failure for the extraction of stones\nin the common bile duct 6,7<\/sup>. In 10% to 20% of cases, stone extraction is not achieved\nusing conventional endoscopic techniques, and it requires instrumentation with\ndifferent ones such as Litotripsy mechanical, extracorporeal, and\nelectro-hydraulic 8<\/sup>.<\/p>\n\n\n\n

Finally, if stone extraction is not achieved with the previously\ndescribed techniques, there is a need for laparoscopic or open surgical\nexploration of the bile duct 9<\/sup>. The absolute frequency of the need\nfor surgical exploration of the bile duct in patients with giant\ncholedocholithiasis is approximately 10% 1<\/sup>. <\/p>\n\n\n\n

Presentation of the case<\/strong><\/p>\n\n\n\n

The case was a\n73-year-old female with a history of important laparoscopic cholecystectomy ten\nyears ago. She referred to having been approached in a health center by those\nwho diagnosed choledocholithiasis de novo. It was referred to the endoscopy\nservice of the General Hospital of Le\u00f3n, and two Endoscopic Retrograde\nCholangioPancreatographies (ERCP) were performed in this unit.<\/p>\n\n\n\n

ERCP with findings: unresolved choledocholithiasis, endoscopic sphincterotomy, intrahepatic and extrahepatic bile duct dilation; placement of a plastic biliary prosthesis<\/p>\n\n\n\n\n\n
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Figure 1: First ERCP<\/strong><\/p>\n

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ERCP with findings: ampulla of Vater with a stent in situ. It was removed without difficulty. An attempt was made to catch the stone with a basket without success due to dimensions (>45 mm). A Tannenbaum-type biliary stent was placed to ensure biliary drainage.<\/p>\n\n\n\n\n\n
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Figure 2: Second ERCP<\/strong><\/p>\n

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Subsequently, she went\nto the general surgery clinic, where the patient was diagnosed with a de novo\ncholedocholithiasis of large elements. Therefore, she was sent to the third\nlevel unit for electrohydraulic intraductal lithotripsy without obtaining a\nsatisfactory response for administrative reasons. The patient was scheduled for\nlaparoscopic bile duct exploration.<\/p>\n\n\n\n

During the surgical procedure, dissection was performed until a\ndilated common bile duct of approximately 3 cm was located.<\/p>\n\n\n\n\n\n
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Figure 3: Common bile duct<\/strong><\/p>\n

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 A 4 cm longitudinal choledochotomy was performed, with abundant biliary debris coming out. Also, a 12 Fr Foley catheter was introduced, and an attempt was made to drag the stone without success.<\/p>\n\n\n\n\n\n
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Figure 4: Foley catheter in choledochotomy for stone removal<\/strong><\/p>\n

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A video-gastroscope was inserted through a 12-mm trocar. As\ncholedochotomy was approached, a 30-mm stone was seen towards the distal common\nbile duct. The extraction with Dormi failed due to the size of the stone. An\nextractor balloon was inserted, disimpacted, and brought closer to the\nsupraduodenal portion for subsequent laparoscopic extraction. Proximal and\ndistal vacuity was verified.<\/p>\n\n\n\n\n\n
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Figure 5: Video-gastroscope in choledochotomy<\/strong><\/p>\n

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Finally, the stone was removed with laparoscopic forceps; Choledochorrhaphy was performed, and a drain was placed.<\/p>\n\n\n\n\n\n
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Figure 6: Stone of large elements outside the common bile duct<\/strong><\/p>\n

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Primary large-element choledocholithiasis is a therapeutic challenge\nfor the general surgeon and endoscopist. The biliodigestive bypass should be\nreserved for select patients 10<\/sup>.<\/p>\n\n\n\n

All the guidelines recommend that choledocholithiasis patient\nmanagement should be adapted to the resources available in each institution 1.\nIn this case, it was decided to perform laparoscopic bile duct exploration with\nthe support of intraoperative choledochoscopy, obtaining the successful\nextraction of the stone in the common bile duct.<\/p>\n\n\n\n

It is important to note that,\nduring the surgical procedure, multiple attempts were made to extract the stone\nfrom the bile duct since its size prevented its easy handling for extraction.\nFinally, it was achieved with the support of the endoscopy service.<\/p>\n\n\n\n

The surgeon’s decision to\nperform laparoscopic bile duct exploration was crucial for managing this case\nsince the stone extraction by ERCP failed on two previous occasions. Therefore,\nit was decided to perform a laparoscopic procedure.<\/p>\n\n\n\n

Conclusion<\/strong><\/p>\n\n\n\n

It is established that endoscopic management should be the first\nguideline for its treatment without neglecting the possibility of surgical\nresolution. Laparoscopic management is a feasible option if there is experience\nand resources for its performance and choosing the surgical procedure having\nthe greatest success described in the literature, currently with lower\nmorbidity and mortality for the patient.<\/p>\n\n\n\n

Acknowledgement<\/strong><\/p>\n\n\n\n

The authors thanks to the patient to give us the consent form signed for her to publish her clinic images.<\/p>\n\n\n\n

Conflict of interest<\/strong><\/p>\n\n\n\n

All authors declare not to have conflict of interest.<\/p>\n\n\n\n

Funding Source<\/strong><\/p>\n\n\n\n

There is no funding sources<\/p>\n\n\n\n

References<\/strong><\/p>\n\n\n\n

  1. ASGE Standards of Practice Committee, Buxbaum JL, Abbas Fehmi SM, Sultan S, Fishman DS, Qumseya BJ, et al. ASGE guideline on the role of endoscopy in the evaluation and management of choledocholithiasis. Gastrointest Endosc. 2019;89(6):1075-1105.e15. DOI: https:\/\/doi.org\/10.1016\/j.gie.2018.10.001
    CrossRef<\/a><\/li>
  2. Andriulli A, Loperfido S, Napolitano G, Niro G, Valvano MR, Spirito F, et al. Incidence rates of post-ERCP complications: a systematic survey of prospective studies. Am J Gastroenterol. 2017;102(8):1781-8. DOI: https:\/\/doi.org\/10.1111\/j.1572-0241-2007.01279.x 
    CrossRef<\/a><\/li>
  3. Bolivar-Rodr\u00edguez MA, Pamanes-Lozano A, Corona-Sapien CF, Fierro-L\u00f3pez R, C\u00e1zarez-Aguilar MA. Coledocolitiasis. Una revision. Rev Med UAS. 2017; 7 (3): 138-154. DOI: http:\/\/dx.doi.org\/10.28960\/revmeduas.2007-8013.v7.n3.005 
    CrossRef <\/a><\/li>
  4. Manes G, Paspatis G, Aabakken L, Anderloni A, Arvanitakis M, Ah-Soune P et al. Endoscopic management of CBD stones. Endoscopy. 2019; 51: 472-491. DOI: https:\/\/doi.org\/10.1055\/a-0862-0346
    CrossRef <\/a><\/li>
  5. Wilkins T, Agabin E, Varghese J, Talukder A. Gallbladder Dysfunction: Cholecystitis, Choledocholithiasis, Cholangitis, and Biliary Dyskinesia. Prim Care. 2017;44(4):575-597. DOI: https:\/\/doi.org\/10.1016\/ j.pop.2017.07.002
    CrossRef <\/a><\/li>
  6. Ram\u00edrez-Garcia J. Factores Relacionados con la Falla Terap\u00e9utica en la Extracci\u00f3n de C\u00e1lculos Coledocianos por Pancreatocolangiograf\u00eda Retr\u00f3grada Endosc\u00f3pica. Revista Peruana de Gastroenterologia. 2011; 31: 330 \u2013 34. DOI: https:\/\/doi.org\/10.47892\/rgp.2011.314.361<\/li>
  7. Katanuma A, Maguchi H, Osanai M, Takahashi K. Endoscopic treatment of difficult common bile duct stones. Digestive Endoscopy 2020; 22 (Supl.1): S90\u2013S97. DOI: https:\/\/doi.org\/10.1111\/j.1443-1661.2010.00979.x 
    CrossRef <\/a><\/li>
  8. Park CH, Jung JH, Nam E, Hye Kim E, Gang Jim M, Hyun Kim J, et al. Comparative efficacy of various endoscopic techniques for the treatment of common bile duct stones: a network meta-analysis. Gastrointest Endosc 2018;87:43-57. DOI: https:\/\/doi.org\/10-1016\/j.gie.2017.07.038
    CrossRef <\/a><\/li>
  9. Sun SX, Kulaylat AN, Hollenbeak CS, Soybel DI. Cost-effective decisions in detecting silent common bile duct gallstones during laparoscopic cholecystectomy. Ann Surg 2016; 263:1164-72. DOI: https:\/\/doi.org\/10.1097\/SLA.0000000000001348
    CrossRef <\/a><\/li>
  10. He H, Tan C, Wu J, Dai N, Hu W, Zhang Y, et al. Accuracy of ASGE high-risk criteria in evaluation of patients with suspected common bile duct stones. Gastrointest Endosc 2017; 86:525-32. DOI: https:\/\/doi.org\/10.1016\/j.gie.2
    CrossRef<\/a><\/li><\/ol>\n","protected":false},"excerpt":{"rendered":"

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