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Endoscopic treatment of problems encountered after cholecystectomy
0016-5107/93/3901-0009$1.00 + .10 GASTROINTESTINAL ENDOSCOPY Copyright © 1993 by the American Society for Gastrointestinal Endoscopy
Endoscopic treatment of problems encountered after cholecystectomy Aram V. Manoukian, MD, Michael J. Schmalz, MD Joseph E. Geenen, MD, Walter J. Hogan, MD Rama P. Venu, MD, G. Kenneth Johnson,MD Racine, Wisconsin, and Milwaukee, Wisconsin
With the advent of laparoscopic cholecystectomy, a number of patients with various postprocedure problems have been referred for endoscopic management. Thirty-five patients were evaluated. The group included 26 women and 9 men, ages 24 to 90 years (mean, 50 years). Twenty-five patients with retained common bile duct stones were successfully treated with endoscopic sphincterotomy and balloon or basket removal. Three patients with bile duct strictures had balloon dilation and endoprosthesis placement and were free of signs of obstruction on 9-month follow-up. Bile leaks were treated successfully with endoscopic sphincterotomy and endoprosthesis placement. Two patients with bile duct leaks and biloma formation required percutaneous or surgical drainage in addition to endoscopic treatment. Three patients had more than one complication. Two patients had strictures with retained stones above the stricture; dilation of the stricture was performed and the stones were removed. One patient with the complication of biliary leak and a long, irregular stricture was treated temporarily by sphincterotomy and stent placement while awaiting surgery. Therapeutic biliary endoscopy is a valuable, minimally invasive alternative to surgery in patients with problems arising after laparoscopic cholecystectomy. (Gastrointest Endosc1993;39:9-14)
Laparoscopic cholecystectomy is a new and innovative technique for the treatment of symptomatic cholelithiasis. Since it was first introduced by Reddick et al'! in 1987, the laparoscopic approach to definitive gallstone treatment has gained widespread popularity because of its shortened length of hospital stay, lower perioperative mortality, and decreased overall rate of complications. 2-4 Although the overall rate of complications appears to be reduced, certain postprocedural problems have been noted, perhaps more frequently than in open cholecystectomy.2, 3, 5-9 Bile duct injuries have been reported in 0.5 % to
Received July 30, 1992. Accepted October 29, 1992. From St. Luke's Hospital, Racine, Wisconsin, and Medical College of Wisconsin, Milwaukee, Wisconsin. Reprint requests: J. E. Geenen, MD, 1333 College Avenue, Racine, WI 53403. 37/1/43896
VOLUME 39, NO.1, 1993
2.7% of laparoscopic cholecystectomy procedures performed in the United States and 0.33 % of those performed in Europe. 6 - 12 In comparison, bile duct injuries associated with conventional cholecystectomy occur in 0.25 % to 0.5 % of cases. 13 Additionally, fistulas, strictures, and bilomas can develop as a result of bile duct injury, which in the past have required a surgical procedure for correction. The reasons for bile duct injuries during laparoscopic cholecystectomy are several; these include a limited visual field, inadequate exposure, and the learning curve inherent to a new procedure. Although the incidence of retained common bile duct stones after laparoscopic cholecystectomy is not known, the estimated rate of retained stones after conventional cholecystectomy can be as high as 10 % .14 During laparoscopic cholecystectomy, these stones may easily be overlooked, especially if intraoperative cholangiography is not performed. In the following report, we describe our experience 9
Table 1. Endoscopic treatment of problems encountered after laparoscopic cholecystectomy Therapeutic intervention Success rate Complication Patient (n) Follow-up ES Complete SE STP CD BD Partial Single complications Common bile duct stones 25 x x 28 days 25 Gallstone pancreatitis 1 x x 1 2 months Bile duct strictures 3 x 3 9.3 months x x x Bile duct leak 1 x x 1 17 months Bile duct leak with biloma 2 x x 2 4.5 months formation Multiple complications Bile duct stricture 2 x 2 11.5 months x x x and stone Bile duct stricture 1 x x x 1 2 months and fistula ES, endoscopic sphincterotomy; SE, stone extraction; STP, stent placement; CD, catheter dilation; RD, balloon dilation. Table 2. Patients with common bile duct stones IOC Patients
IOC positive Yes
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
No
x
x x x
x x
x x x x x x
x x x x x x x x
x x x x
x
x x x x x
x x x x x
x x x x
Abnormal liver function tests
Pain
No Yes Yes Yes No Yes Yes Yes No Yes Yes Yes No Yes Yes No Yes Yes Yes No No No No Yes Yes
Yes Yes Yes No Yes No No No No Yes Yes Yes Yes No Yes No Yes Yes No No No No Yes Yes Yes
IOC, intraoperative cholangiogram.
with the endoscopic management of laparoscopic cholecystectomy complications. METHODS
A total of 35 patients with laparoscopic cholecystectomy complications were evaluated during a 20-month period from 1990 to 1992. The group included 26 women and 9 men. Ages ranged from 24 to 90 years; the mean age was 50 years. The laparoscopic cholecystectomy problems seen were both singular and multiple (Table 1). In those with a single problem, 25 patients had common bile duct stones, 1 patient 10
had gallstone pancreatitis, 3 patients had bile duct strictures, and 3 patients had bile duct leakage. Two of these patients had associated biloma formation. Three patients had multiple complications associated with laparoscopic cholecystectomy. Two patients had retained stones with an associated bile duct stricture. One patient had both a bile duct stricture and leakage. On initial evaluation, routine blood tests were obtained for complete blood count, amylase level, blood chemistries, and coagulation panel before ERCP. On the identification of a bile duct abnormality at ERCP, therapeutic modalities including standard endoscopic sphincterotomy, catheter dilation, balloon dilation, and endoprosthesis placement were used singularly or in combination. Diagnostic ERCP was performed using either the Olympus JF 3.2-mm or 4.2-mm channel duodenoscope (Olympus Corp., Lake Success, N.Y.). The larger channel endoscopes were used when a strong likelihood existed that large-caliber stents would be needed or when mechanical lithotripsy would be required. Prophylactic antibiotics were administered before and after the procedure to all patients to prevent postprocedure cholangitis. After cannulation, visualization of the biliary system was accomplished during slow contrast injection under close fluoroscopic monitoring. The diameter and length of the stricture were carefully assessed by radiography before selecting the method of bile duct dilation. A sphincterotomy was performed when large-caliber stent placement was anticipated. Guide wire access across the strictured area was performed after sphincterotomy. Catheter dilators (3F to 11.5F; Soehendra, Wilson-Cook, Inc., Winston-Salem, N.C.) were used initially to dilate the strictures. After this dilation, balloon catheters (180 cm length; 5F or 8F balloon, diameter 4 to 10 mm) were passed across the strictured area over a guide wire. With the use of fluoroscopy, the balloons were inflated with contrast to 4 to 8 atm with pressure maintained for 30 seconds. Several inflations were carried out, with close attention to the contour of the waist in the balloon and the patient's tolerance to the dilation. After this procedure, biliary endoprostheses (7F to 11.5F) were inserted over a guide wire and positioned across the stricture. Dilation and stenting were repeated at 3-month to 6-month intervals, based on the persistence of the stricture. The endoprosthesis was not reGASTROINTESTINAL ENDOSCOPY
duct stricture identified at the time of diag-
Figure. 2. After guide wire placement and catheter dilation, the stricture is balloon dilated and a waist is noted.
placed when the stricture disappeared or when the degree of narrowing was minimal. The outcome of endoscopic treatment on biliary strictures was assessed by comparing symptoms, liver enzymes, and stricture size between the initial and final ERCP examination. When a biliary fistula was encountered, a sphincterotomy was performed. Guide wire access to the proximal bile duct was established, and the duct was stented with 7F to 11.5F endoprostheses. These stents were usually removed, ordinarily at 1 month, and a cholangiogram was obtained to determine whether leakage was present. When dilation was needed in the presence of biliary fistulas, only catheter dilation of the duct was performed.
The interval between laparoscopic cholecystectomy and diagnostic ERCP ranged from 1 day to 12 weeks, with a mean of 21.2 days (Table 2). Common bile duct stones were treated successfully by routine methods, including endoscopic sphincterotomy with balloon or basket extraction in all 25 patients. No complications occurred with sphincterotomy. All of these patients did well and had no signs of recurrent biliary obstruction on a mean follow-up of approximately 1 month. One patient had gallstone pancreatitis and jaundice develop 4 months after laparoscopic cholecystectomy. A sonogram suggested a common hepatic duct stone. At ERCP the retained stone was found in the common bile duct and removed. The patient did well for 2 months but subsequently had an episode of unexplained pancreatitis. Three patients had common hepatic duct strictures develop after laparoscopic cholecystectomy. All patients presented with jaundice; one patient had biliary pain. The interval from the time of laparoscopic cholecystectomy ranged from 1 to 6 months. In the first patient, a high-grade stricture of the
Figure. 1. Bile nostic ERCP.
RESULTS
Retained common bile duct stones were noted intraoperatively by cholangiography in 15 of 25 patients. Only 7 of these 15 patients had abnormal liver function tests. Ten of the 25 patients had common bile duct stones diagnosed postoperatively. Nine of the patients had recurrent biliary pain, and nine had abnormal liver chemistries. Three of these patients were jaundiced. VOLUME 39, NO.1, 1993
11
Figure. 4. At the time of diagnostic ERCP, a biliary fistula
is noted in the region of several surgical clips.
Figure. 3. After three successive dilations, no further waist
is noted and the balloon is removed. On repeat cholangiography, no residual stricture remains. Because of their tendency to reform, a stent was subsequently placed across the strictured area.
common hepatic duct was dilated by catheter and balloon, and a 7F, 9-cm bile duct stent was placed (Figs. 1-3). Two months later, repeat balloon dilation and stenting were performed. Two additional procedures were performed at 4 months and 10 months, at which time 11.5F stents were placed. The patient did well without signs or symptoms of recurrent obstruction. The diameter of the stricture had increased from 1 mm to 4 mm at 1 year. The second patient had a common hepatic duct stricture develop 5 months after laparoscopic cholecystectomy. At ERCP, endoscopic sphincterotomy was performed, the stricture catheter dilated then stented with a 7F endoprosthesis. Subsequently, the stricture was dilated to accommodate an 11.5F stent. At the 10-month follow-up the patient continues to do well. The last patient developed painless jaundice 6 months after laparoscopic cholecystectomy. At ERCP a stricture was noted, balloon dilation carried out, and 12
an 11.5F endoprosthesis was placed. The duct has been stented for 6 months at the time ofthis writing, and the patient remains asymptomatic. An uncomplicated biliary fistula occurred in one patient after laparoscopic cholecystectomy (Figs. 4 and 5). Painless jaundice was diagnosed in this patient soon after surgery. The leak was noted at the time of ERCP, with extravasation of contrast in the region of several surgical clips near the cystic duct remnant. A sphincterotomy was performed, and a biliary endoprosthesis was placed across the leak for 3 months. At repeat ERCP the fistula had sealed; however, a biliary stricture had developed in the area. This stricture was balloon dilated and stented with an 11.5F endoprosthesis, which remained in place for 6 months. At that time an ERCP showed a noticeable improvement in the diameter of the stricture. The area was therefore balloon dilated without stent replacement. Follow-up ERCP 8 months later revealed only a minimal narrowing of the bile duct. Biliary fistulas and complicating biloma formation occurred in two patients. Abdominal pain and abnormal liver chemistries were diagnosed in one patient 14 days after surgery. An ERCP revealed a fistula adjacent to the cystic duct remnant. An endoscopic sphincterotomy was performed, and a bile duct stent was placed. Four days later the biloma was surgically drained. Six weeks later the stent was removed, and the bile duct appeared normal on cholangiography. Three months after surgery a CT scan showed no evidence ofbiloma recurrence. The patient has done well on 4-month follow-up. The other biloma patient had pain develop within 2 weeks of laparoscopic cholecystectomy. An ERCP revealed a biliary fistula in the region of the common hepatic duct. A 7F stent was placed. Within 1 week of this procedure the biloma was drained percutaneously. The endoprosthesis was removed in 1 month, and GASTROINTESTINAL ENDOSCOPY
cholangiography was normal. The patient has been asymptomatic more than 5 months. Endoscopic sphincterotomy was performed in conjunction with stent placement in our biliary fistula patients to ensure decompression of the duct and to facilitate stent placement and subsequent repeat cannulations if necessary. Biliary fistula and stricture formation occurred postoperatively in one patient. This patient became jaundiced 7 days after the procedure, and a HIDA scan revealed the biliary fistula. A laparotomy was performed, a T tube was placed across the common hepatic duct defect, and the biloma was drained. Two weeks later a T-tube cholangiogram revealed a persistent leak. At ERCP, a 2- to 3-cm common hepatic duct stricture was identified. Over a 2-week period the stricture was dilated to accommodate a 7F endoprosthesis, with cessation of T-tube drainage. Despite successful endoscopic therapy, concern existed that the bile duct injury was too extensive. For this reason the patient was referred for biliary bypass surgery, which she underwent 2 months later. Two patients were found to have a bile duct stricture and retained stones. One patient with normal liver chemistries had biliary pain develop 6 weeks after laparoscopic cholecystectomy. Common bile duct exploration was performed, multiple stones were noted, and a T tube was placed. Two weeks later an ERCP was performed because of recurrent symptoms. A distal common bile duct stricture and retained common bile duct stones were identified. An endoscopic sphincterotomy was performed, the stricture catheter was dilated, and the stones were removed. The T tube has been subsequently removed, and during a 9-month follow-up period the patient has been asymptomatic. A second patient had pain and jaundice develop several days after laparoscopic cholecystectomy. On ERCP, a 7-mm-Iong common hepatic duct stricture was observed, with stones in the proximal duct. An endoscopic sphincterotomy was performed, the stricture balloon dilated, and the stones were removed. A 10F stent was placed. The stricture was stented for 9 months with an 11.5F endoprosthesis. Six months after stent removal, ERCP revealed only a minimal residual stricture, which was balloon dilated. The patient continues to do well. DISCUSSION
Laparoscopic cholecystectomy is rapidly becoming the procedure of choice for symptomatic cholelithiasis. With the increased demand, surgeons have hastened to acquire the necessary skills. Although this technique promises decreased rates of morbidity, mortality, and length of hospital stay, certain complications, either at the same rate or exceeding those of standard cholecystectomy, have been noted. Problems encounVOLUME 39, NO.1, 1993
Figure. 5. After identification of the bile duct injury, a sphincterotomy was performed, guide wire access was established, and a biliary endoprosthesis was placed.
tered at laparoscopic cholecystectomy stem from anatomic variability, unrecognized choledocholithiasis, and technical difficulties. Endoscopic treatment of the complications of laparoscopic cholecystectomy provide a less invasive therapy and may prevent repeat operation. Extended treatment of postoperative bile duct strictures by endoscopic techniques has been described elsewhere. 15 , 16 We observed three patients for a mean of 9 months who had stricture dilation and stent placement at periodic intervals. During that period, each patient did well, with resolution of these symptoms and signs attributable to biliary obstruction. Our current management of ductal strictures is periodic dilation and stent placement for at least 1 year. Subsequent management of strictures is dependent on response to dilation and stenting. If a good result is obtained, that is, no evidence of stricture reformation or easy balloon dilation after stent removal is observed, the patients are observed expectantly. Periodic liver function studies are obtained and repeat ERCP with dilation as needed is performed for chemical evidence 13
of restenosis. Long-term response to stenting is undoubtedly contingent on the degree of the original injury. It is conceivable that some of these patients may require long-term stenting, repeated dilations, or even eventual surgery. We found liver chemistries alone to be only a fair indicator for the presence of choledocholithiasis because 9 of 25 patients with common bile duct stones in our series had normal liver function tests. When deciding to perform intraoperative cholangiography or preprocedural ERCP, we believe a reasonable approach would be the following. When liver chemistries are normal and no ductal dilation is found on sonography, laparoscopic cholecystectomy without intraoperative cholangiography or ERCP is our suggested approach. Certainly, in the case where liver chemistries are abnormal and ductal enlargement is seen, preoperative ERCP, especially when an open procedure is prohibitive, is recommended. In the case where either dilated ducts are seen or abnormal liver function tests are noted, intraoperative cholangiography to evaluate for the presence of choledocholithiasis is encouraged. If this is not possible, then a preprocedural ERCP is recommended. In any clinical situation in which a suspicion of biliary abnormality exists, an ERCP should be performed before laparoscopic cholecystectomy. In this way, an unsuspected pathologic finding such as occult malignancy can be identified, and appropriate therapy can be planned. In addition, the large common bile duct stone, which requires special expertise for removal, can be addressed before surgery either by referral to an appropriate endoscopic center or by reconsidering open cholecystectomy with common bile duct exploration. The successful treatment of biliary fistulas with endoscopic sphincterotomy and endoprosthesis placement has been evaluated in the past. 5 , 17, 18 In our experience, uncomplicated biliary fistulas respond to endoscopic treatment. When the fistula is complicated
14
by biloma formation, percutaneous or surgical drainage may be required. On the basis of our experience, therapeutic biliary endoscopy is a valuable, minimally invasive alternative to surgery for those problems noted after laparoscopic cholecystectomy.
REFERENCES 1. Reddick EJ, Olsen DO, Daniell JF, et al. Laparoscopic laser cholecystectomy. Laser Med Surg News Adv 1989;7:38-40. 2. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopic cholecystectomies. N Engl J Med 1991;324:107378. 3. Salky BA, Bauer JJ. Laparoscopic cholecystectomy: an initial report. Gastrointest Endosc 1991;37:1-4. 4. Goodman GR, Hunter JG. Results of laparoscopic cholecystectomy in a university hospital. Am J Surg 1991;162:576-9. 5. Kozarek RA, Gannan R, Baerg R, Wagonfeld J, Ball T. Bile leak after laparoscopic cholecystectomy: diagnostic and therapeutic application of ERCP. Arch Intern Med 1992;152:1040-2. 6. Peters JH, Ellison C, Innes JT, et al. Safety and efficacy of laparoscopic cholecystectomy. Ann Surg 1991;213:3-12. 7. Berci G, Sarkier JM. The Los Angeles experience with laparoscopic cholecystectomy. Am J Surg 1991;161:382-4. 8. Olsen DO. Laparoscopic cholecystectomy. Am J Surg 1991;161: 339-44. 9. Cuschieri A, Dubois F, Mourel J, et al. The European experience with laparoscopic cholecystectomy. Am J Surg 1991;161:385-7. 10. Zucker KA, Bailey RW, Gadacz TR, Imbembo AL. Laparoscopic guided cholecystectomy. Am J Surg 1991;161:36-44. 11. Reddick EJ. Laparoscopic laser cholecystectomy: the first 50 cases. Laser Surg Med 1990;10(suppl 2):21. 12. Schultz LS, Hickok DF, Graber JH, et al. Laparoscopic cholecystectomy: a clinical trial. Laser Surg Med 1990;10(suppI2):25. 13. Moosa AR, Mayer AD, Stabile B. Iatrogenic injuries to the bile duct. Arch Surg 1990;125:1028-30. 14. Ponsky JL. Complications oflaparoscopic cholecystectomy. Am J Surg 1991;161:393-5. 15. Geenen DJ, Geenen JE, Hogan WJ, et al. Endoscopic therapy of benign bile duct strictures. Gastrointest Endosc 1989;35:36771. 16. Davids PHD, Rauws EAJ, Coene PPLO, Tytgat GNJ, Huibregtse K. Endoscopic stenting for postoperative biliary strictures. Gastrointest Endosc 1992;38:12-18. 17. O'Rahilly S, Duignan VP, Lennon JR, O'Malley E. Successful treatment of a postoperative external biliary fistula by endoscopic papillotomy. Endoscopy 1983;15:68-9. 18. Ponchon T, Gallez J-F, Valette P-J, Chavaillon A, Bory R. Endoscopic treatment of biliary tract fistulas. Gastrointest Endosc 1989;35:490-8.
GASTROINTESTINAL ENDOSCOPY
Endoscopic treatment of problems encountered after cholecystectomy Aram V. Manoukian, MD, Michael J. Schmalz, MD Joseph E. Geenen, MD, Walter J. Hogan, MD Rama P. Venu, MD, G. Kenneth Johnson,MD Racine, Wisconsin, and Milwaukee, Wisconsin
With the advent of laparoscopic cholecystectomy, a number of patients with various postprocedure problems have been referred for endoscopic management. Thirty-five patients were evaluated. The group included 26 women and 9 men, ages 24 to 90 years (mean, 50 years). Twenty-five patients with retained common bile duct stones were successfully treated with endoscopic sphincterotomy and balloon or basket removal. Three patients with bile duct strictures had balloon dilation and endoprosthesis placement and were free of signs of obstruction on 9-month follow-up. Bile leaks were treated successfully with endoscopic sphincterotomy and endoprosthesis placement. Two patients with bile duct leaks and biloma formation required percutaneous or surgical drainage in addition to endoscopic treatment. Three patients had more than one complication. Two patients had strictures with retained stones above the stricture; dilation of the stricture was performed and the stones were removed. One patient with the complication of biliary leak and a long, irregular stricture was treated temporarily by sphincterotomy and stent placement while awaiting surgery. Therapeutic biliary endoscopy is a valuable, minimally invasive alternative to surgery in patients with problems arising after laparoscopic cholecystectomy. (Gastrointest Endosc1993;39:9-14)
Laparoscopic cholecystectomy is a new and innovative technique for the treatment of symptomatic cholelithiasis. Since it was first introduced by Reddick et al'! in 1987, the laparoscopic approach to definitive gallstone treatment has gained widespread popularity because of its shortened length of hospital stay, lower perioperative mortality, and decreased overall rate of complications. 2-4 Although the overall rate of complications appears to be reduced, certain postprocedural problems have been noted, perhaps more frequently than in open cholecystectomy.2, 3, 5-9 Bile duct injuries have been reported in 0.5 % to
Received July 30, 1992. Accepted October 29, 1992. From St. Luke's Hospital, Racine, Wisconsin, and Medical College of Wisconsin, Milwaukee, Wisconsin. Reprint requests: J. E. Geenen, MD, 1333 College Avenue, Racine, WI 53403. 37/1/43896
VOLUME 39, NO.1, 1993
2.7% of laparoscopic cholecystectomy procedures performed in the United States and 0.33 % of those performed in Europe. 6 - 12 In comparison, bile duct injuries associated with conventional cholecystectomy occur in 0.25 % to 0.5 % of cases. 13 Additionally, fistulas, strictures, and bilomas can develop as a result of bile duct injury, which in the past have required a surgical procedure for correction. The reasons for bile duct injuries during laparoscopic cholecystectomy are several; these include a limited visual field, inadequate exposure, and the learning curve inherent to a new procedure. Although the incidence of retained common bile duct stones after laparoscopic cholecystectomy is not known, the estimated rate of retained stones after conventional cholecystectomy can be as high as 10 % .14 During laparoscopic cholecystectomy, these stones may easily be overlooked, especially if intraoperative cholangiography is not performed. In the following report, we describe our experience 9
Table 1. Endoscopic treatment of problems encountered after laparoscopic cholecystectomy Therapeutic intervention Success rate Complication Patient (n) Follow-up ES Complete SE STP CD BD Partial Single complications Common bile duct stones 25 x x 28 days 25 Gallstone pancreatitis 1 x x 1 2 months Bile duct strictures 3 x 3 9.3 months x x x Bile duct leak 1 x x 1 17 months Bile duct leak with biloma 2 x x 2 4.5 months formation Multiple complications Bile duct stricture 2 x 2 11.5 months x x x and stone Bile duct stricture 1 x x x 1 2 months and fistula ES, endoscopic sphincterotomy; SE, stone extraction; STP, stent placement; CD, catheter dilation; RD, balloon dilation. Table 2. Patients with common bile duct stones IOC Patients
IOC positive Yes
1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25
No
x
x x x
x x
x x x x x x
x x x x x x x x
x x x x
x
x x x x x
x x x x x
x x x x
Abnormal liver function tests
Pain
No Yes Yes Yes No Yes Yes Yes No Yes Yes Yes No Yes Yes No Yes Yes Yes No No No No Yes Yes
Yes Yes Yes No Yes No No No No Yes Yes Yes Yes No Yes No Yes Yes No No No No Yes Yes Yes
IOC, intraoperative cholangiogram.
with the endoscopic management of laparoscopic cholecystectomy complications. METHODS
A total of 35 patients with laparoscopic cholecystectomy complications were evaluated during a 20-month period from 1990 to 1992. The group included 26 women and 9 men. Ages ranged from 24 to 90 years; the mean age was 50 years. The laparoscopic cholecystectomy problems seen were both singular and multiple (Table 1). In those with a single problem, 25 patients had common bile duct stones, 1 patient 10
had gallstone pancreatitis, 3 patients had bile duct strictures, and 3 patients had bile duct leakage. Two of these patients had associated biloma formation. Three patients had multiple complications associated with laparoscopic cholecystectomy. Two patients had retained stones with an associated bile duct stricture. One patient had both a bile duct stricture and leakage. On initial evaluation, routine blood tests were obtained for complete blood count, amylase level, blood chemistries, and coagulation panel before ERCP. On the identification of a bile duct abnormality at ERCP, therapeutic modalities including standard endoscopic sphincterotomy, catheter dilation, balloon dilation, and endoprosthesis placement were used singularly or in combination. Diagnostic ERCP was performed using either the Olympus JF 3.2-mm or 4.2-mm channel duodenoscope (Olympus Corp., Lake Success, N.Y.). The larger channel endoscopes were used when a strong likelihood existed that large-caliber stents would be needed or when mechanical lithotripsy would be required. Prophylactic antibiotics were administered before and after the procedure to all patients to prevent postprocedure cholangitis. After cannulation, visualization of the biliary system was accomplished during slow contrast injection under close fluoroscopic monitoring. The diameter and length of the stricture were carefully assessed by radiography before selecting the method of bile duct dilation. A sphincterotomy was performed when large-caliber stent placement was anticipated. Guide wire access across the strictured area was performed after sphincterotomy. Catheter dilators (3F to 11.5F; Soehendra, Wilson-Cook, Inc., Winston-Salem, N.C.) were used initially to dilate the strictures. After this dilation, balloon catheters (180 cm length; 5F or 8F balloon, diameter 4 to 10 mm) were passed across the strictured area over a guide wire. With the use of fluoroscopy, the balloons were inflated with contrast to 4 to 8 atm with pressure maintained for 30 seconds. Several inflations were carried out, with close attention to the contour of the waist in the balloon and the patient's tolerance to the dilation. After this procedure, biliary endoprostheses (7F to 11.5F) were inserted over a guide wire and positioned across the stricture. Dilation and stenting were repeated at 3-month to 6-month intervals, based on the persistence of the stricture. The endoprosthesis was not reGASTROINTESTINAL ENDOSCOPY
duct stricture identified at the time of diag-
Figure. 2. After guide wire placement and catheter dilation, the stricture is balloon dilated and a waist is noted.
placed when the stricture disappeared or when the degree of narrowing was minimal. The outcome of endoscopic treatment on biliary strictures was assessed by comparing symptoms, liver enzymes, and stricture size between the initial and final ERCP examination. When a biliary fistula was encountered, a sphincterotomy was performed. Guide wire access to the proximal bile duct was established, and the duct was stented with 7F to 11.5F endoprostheses. These stents were usually removed, ordinarily at 1 month, and a cholangiogram was obtained to determine whether leakage was present. When dilation was needed in the presence of biliary fistulas, only catheter dilation of the duct was performed.
The interval between laparoscopic cholecystectomy and diagnostic ERCP ranged from 1 day to 12 weeks, with a mean of 21.2 days (Table 2). Common bile duct stones were treated successfully by routine methods, including endoscopic sphincterotomy with balloon or basket extraction in all 25 patients. No complications occurred with sphincterotomy. All of these patients did well and had no signs of recurrent biliary obstruction on a mean follow-up of approximately 1 month. One patient had gallstone pancreatitis and jaundice develop 4 months after laparoscopic cholecystectomy. A sonogram suggested a common hepatic duct stone. At ERCP the retained stone was found in the common bile duct and removed. The patient did well for 2 months but subsequently had an episode of unexplained pancreatitis. Three patients had common hepatic duct strictures develop after laparoscopic cholecystectomy. All patients presented with jaundice; one patient had biliary pain. The interval from the time of laparoscopic cholecystectomy ranged from 1 to 6 months. In the first patient, a high-grade stricture of the
Figure. 1. Bile nostic ERCP.
RESULTS
Retained common bile duct stones were noted intraoperatively by cholangiography in 15 of 25 patients. Only 7 of these 15 patients had abnormal liver function tests. Ten of the 25 patients had common bile duct stones diagnosed postoperatively. Nine of the patients had recurrent biliary pain, and nine had abnormal liver chemistries. Three of these patients were jaundiced. VOLUME 39, NO.1, 1993
11
Figure. 4. At the time of diagnostic ERCP, a biliary fistula
is noted in the region of several surgical clips.
Figure. 3. After three successive dilations, no further waist
is noted and the balloon is removed. On repeat cholangiography, no residual stricture remains. Because of their tendency to reform, a stent was subsequently placed across the strictured area.
common hepatic duct was dilated by catheter and balloon, and a 7F, 9-cm bile duct stent was placed (Figs. 1-3). Two months later, repeat balloon dilation and stenting were performed. Two additional procedures were performed at 4 months and 10 months, at which time 11.5F stents were placed. The patient did well without signs or symptoms of recurrent obstruction. The diameter of the stricture had increased from 1 mm to 4 mm at 1 year. The second patient had a common hepatic duct stricture develop 5 months after laparoscopic cholecystectomy. At ERCP, endoscopic sphincterotomy was performed, the stricture catheter dilated then stented with a 7F endoprosthesis. Subsequently, the stricture was dilated to accommodate an 11.5F stent. At the 10-month follow-up the patient continues to do well. The last patient developed painless jaundice 6 months after laparoscopic cholecystectomy. At ERCP a stricture was noted, balloon dilation carried out, and 12
an 11.5F endoprosthesis was placed. The duct has been stented for 6 months at the time ofthis writing, and the patient remains asymptomatic. An uncomplicated biliary fistula occurred in one patient after laparoscopic cholecystectomy (Figs. 4 and 5). Painless jaundice was diagnosed in this patient soon after surgery. The leak was noted at the time of ERCP, with extravasation of contrast in the region of several surgical clips near the cystic duct remnant. A sphincterotomy was performed, and a biliary endoprosthesis was placed across the leak for 3 months. At repeat ERCP the fistula had sealed; however, a biliary stricture had developed in the area. This stricture was balloon dilated and stented with an 11.5F endoprosthesis, which remained in place for 6 months. At that time an ERCP showed a noticeable improvement in the diameter of the stricture. The area was therefore balloon dilated without stent replacement. Follow-up ERCP 8 months later revealed only a minimal narrowing of the bile duct. Biliary fistulas and complicating biloma formation occurred in two patients. Abdominal pain and abnormal liver chemistries were diagnosed in one patient 14 days after surgery. An ERCP revealed a fistula adjacent to the cystic duct remnant. An endoscopic sphincterotomy was performed, and a bile duct stent was placed. Four days later the biloma was surgically drained. Six weeks later the stent was removed, and the bile duct appeared normal on cholangiography. Three months after surgery a CT scan showed no evidence ofbiloma recurrence. The patient has done well on 4-month follow-up. The other biloma patient had pain develop within 2 weeks of laparoscopic cholecystectomy. An ERCP revealed a biliary fistula in the region of the common hepatic duct. A 7F stent was placed. Within 1 week of this procedure the biloma was drained percutaneously. The endoprosthesis was removed in 1 month, and GASTROINTESTINAL ENDOSCOPY
cholangiography was normal. The patient has been asymptomatic more than 5 months. Endoscopic sphincterotomy was performed in conjunction with stent placement in our biliary fistula patients to ensure decompression of the duct and to facilitate stent placement and subsequent repeat cannulations if necessary. Biliary fistula and stricture formation occurred postoperatively in one patient. This patient became jaundiced 7 days after the procedure, and a HIDA scan revealed the biliary fistula. A laparotomy was performed, a T tube was placed across the common hepatic duct defect, and the biloma was drained. Two weeks later a T-tube cholangiogram revealed a persistent leak. At ERCP, a 2- to 3-cm common hepatic duct stricture was identified. Over a 2-week period the stricture was dilated to accommodate a 7F endoprosthesis, with cessation of T-tube drainage. Despite successful endoscopic therapy, concern existed that the bile duct injury was too extensive. For this reason the patient was referred for biliary bypass surgery, which she underwent 2 months later. Two patients were found to have a bile duct stricture and retained stones. One patient with normal liver chemistries had biliary pain develop 6 weeks after laparoscopic cholecystectomy. Common bile duct exploration was performed, multiple stones were noted, and a T tube was placed. Two weeks later an ERCP was performed because of recurrent symptoms. A distal common bile duct stricture and retained common bile duct stones were identified. An endoscopic sphincterotomy was performed, the stricture catheter was dilated, and the stones were removed. The T tube has been subsequently removed, and during a 9-month follow-up period the patient has been asymptomatic. A second patient had pain and jaundice develop several days after laparoscopic cholecystectomy. On ERCP, a 7-mm-Iong common hepatic duct stricture was observed, with stones in the proximal duct. An endoscopic sphincterotomy was performed, the stricture balloon dilated, and the stones were removed. A 10F stent was placed. The stricture was stented for 9 months with an 11.5F endoprosthesis. Six months after stent removal, ERCP revealed only a minimal residual stricture, which was balloon dilated. The patient continues to do well. DISCUSSION
Laparoscopic cholecystectomy is rapidly becoming the procedure of choice for symptomatic cholelithiasis. With the increased demand, surgeons have hastened to acquire the necessary skills. Although this technique promises decreased rates of morbidity, mortality, and length of hospital stay, certain complications, either at the same rate or exceeding those of standard cholecystectomy, have been noted. Problems encounVOLUME 39, NO.1, 1993
Figure. 5. After identification of the bile duct injury, a sphincterotomy was performed, guide wire access was established, and a biliary endoprosthesis was placed.
tered at laparoscopic cholecystectomy stem from anatomic variability, unrecognized choledocholithiasis, and technical difficulties. Endoscopic treatment of the complications of laparoscopic cholecystectomy provide a less invasive therapy and may prevent repeat operation. Extended treatment of postoperative bile duct strictures by endoscopic techniques has been described elsewhere. 15 , 16 We observed three patients for a mean of 9 months who had stricture dilation and stent placement at periodic intervals. During that period, each patient did well, with resolution of these symptoms and signs attributable to biliary obstruction. Our current management of ductal strictures is periodic dilation and stent placement for at least 1 year. Subsequent management of strictures is dependent on response to dilation and stenting. If a good result is obtained, that is, no evidence of stricture reformation or easy balloon dilation after stent removal is observed, the patients are observed expectantly. Periodic liver function studies are obtained and repeat ERCP with dilation as needed is performed for chemical evidence 13
of restenosis. Long-term response to stenting is undoubtedly contingent on the degree of the original injury. It is conceivable that some of these patients may require long-term stenting, repeated dilations, or even eventual surgery. We found liver chemistries alone to be only a fair indicator for the presence of choledocholithiasis because 9 of 25 patients with common bile duct stones in our series had normal liver function tests. When deciding to perform intraoperative cholangiography or preprocedural ERCP, we believe a reasonable approach would be the following. When liver chemistries are normal and no ductal dilation is found on sonography, laparoscopic cholecystectomy without intraoperative cholangiography or ERCP is our suggested approach. Certainly, in the case where liver chemistries are abnormal and ductal enlargement is seen, preoperative ERCP, especially when an open procedure is prohibitive, is recommended. In the case where either dilated ducts are seen or abnormal liver function tests are noted, intraoperative cholangiography to evaluate for the presence of choledocholithiasis is encouraged. If this is not possible, then a preprocedural ERCP is recommended. In any clinical situation in which a suspicion of biliary abnormality exists, an ERCP should be performed before laparoscopic cholecystectomy. In this way, an unsuspected pathologic finding such as occult malignancy can be identified, and appropriate therapy can be planned. In addition, the large common bile duct stone, which requires special expertise for removal, can be addressed before surgery either by referral to an appropriate endoscopic center or by reconsidering open cholecystectomy with common bile duct exploration. The successful treatment of biliary fistulas with endoscopic sphincterotomy and endoprosthesis placement has been evaluated in the past. 5 , 17, 18 In our experience, uncomplicated biliary fistulas respond to endoscopic treatment. When the fistula is complicated
14
by biloma formation, percutaneous or surgical drainage may be required. On the basis of our experience, therapeutic biliary endoscopy is a valuable, minimally invasive alternative to surgery for those problems noted after laparoscopic cholecystectomy.
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