Journal of Postgraduate Medicine Medknow Publications and Staff Society of Seth GS Medical College and KEM Hospital, Mumbai, India ISSN: 0022-3859 EISSN: 0972-2823 Vol. 51, Num. 2, 2005, pp. 156-157

Journal of Postgraduate Medicine, Vol. 51, No. 2, April-June, 2005, pp. 156-157

Letters

Laparoscopic choledochoduodenostomy for retained bile duct stone

Bhandarkar Deepraj S., Shah R.S.

Departments of Surgery, Sir Hurkisondas Nurrotumdas Hospital and Research Center, Padmashree Gordhanbapa Chowk, Mumbai - 400 004

Correspondence Address: Departments of Surgery, Sir Hurkisondas Nurrotumdas Hospital and Research Center, Padmashree Gordhanbapa Chowk, Mumbai - 400 004, deeprajbhandarkar@hotmail.com

Code Number: jp05064

Sir,

A 68-year-old woman who had undergone laparoscopic cholecystectomy (LC) at another institution 30 months ago presented with right upper quadrant pain. Liver function tests and bile duct diameter prior to this surgery were normal. A year after the LC she was found to have bile duct stones for which two ERCPs and stone extractions were performed and a biliary stent inserted. During the present admission, haematological and biochemical investigations were normal except raised liver enzymes (AST, ALT and alkaline phosphatase). Ultrasonography revealed a bile duct dilated to 18-mm with a 10-mm stone and the stent within; magnetic resonance cholangiopancreatography confirmed the findings [Figure - 1].

Laparoscopic surgery was performed using two 10-mm and one 5-mm port. After freeing the undersurface of the liver adherent to the porta hepatis, a table-mounted retractor system was set up to retract the liver. The bile duct was identified and exposed. The duodenum was Kocherised widely. A 2.5 cm anterior supraduodenal choledochotomy was made and a choledochoscope was introduced. The single bile duct stone was extracted using a Dormia basket. A 2.5 cm incision was made at the junction of the first and second parts of the duodenum and a side-to-side, single-layered choledocho-duodenostomy (LCD) was fashioned using interrupted 4/0 polyglycolic acid sutures. The biliary stent present was left undisturbed and a suction drain placed in the subhepatic region. She had an uneventful recovery and was discharged on the 5^th postoperative day. The stent was removed at 6 weeks, and she remains asymptomatic a year later.

The standard treatment for stones retained in the bile ducts following LC involves ERCP, endoscopic sphincterotomy and stone extraction; the success rate of this procedure approaches 100% in experienced hands. In patients in whom ERCP fails, an open operation in the form of a bile duct exploration may be required. In view of the failure of two previous ERCP procedures to clear the bile duct our patient was offered laparoscopic therapy. The presence of a dilated bile duct prompted us to consider a bilioenteric anastomosis rather than a mere choledocholithotomy.

In recent years, laparoscopic surgery is being increasingly utilised in the management of bile duct calculi as a primary therapy or when ERCP is unsuccessful. However, the use of LCD is limited. LCD was first reported by Rhodes and Nathanson[1] in two patients with recurrent bile duct stones developing several years after cholecystectomy which could not be extracted by ERCP. Tinoco et al in 1999 described the use of LCD in 19 patients with choledocholithiasis and in 6 patients to relieve obstructive jaundice resulting from unresectable pancreatic neoplasms.[2] It is debatable whether the latter forms an appropriate indication for LCD. Jeyapalan et al reviewed their experience of 16 LCDs over 11 years[3] and found it to be a safe and effective procedure for treating patients with benign bile duct obstruction from stone disease. More recently, Tang et al used LCD as an effective drainage procedure in 12 patients with recurrent pyogenic cholangitis.[4]

Some technical aspects of LCD merit highlighting. Like its open counterpart, the performance of LCD mandates that the bile duct be dilated to at least 1.5 cm. The anastomosis can either be end-to-side or side-to-side; the latter approach is simpler as it does not require extensive circumferential dissection of the bile duct. Wide mobilisation of the duodenum ensures a tension-free anastomosis. A stoma of > 2 cm reduces the chances of anastomotic stenosis in the long term. Exteriorisation of the first posterior suture placed at the cephalad corner and elevation of the anastomosis facilitates placement of subsequent sutures. Postoperative biliary decompression is seldom required. However, if a biliary stent is in place, as was in our patient, it should be left in situ and removed subsequently.

In conclusion, LCD appears to be a safe and effective option in patients with stones in a dilated bile duct when endoscopic clearance has failed. The role of LCD for other indications may become clearer as and when data from larger prospective series is published.

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Copyright 2005 - Journal of Postgraduate Medicine

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