Anterograde biliary stenting during laparoscopic cholecystectomy as a rescue maneuver in extensive choledocholithiasis

Abstract text (incl. references and figure legends)

Introduction: In case of choledocholithiasis therapeutic gold standard is endoscopic retrograde cholangiography (ERC) with stone extraction ± stent placement followed by laparoscopic cholecystectomy (lap CHE). When unnoticed choledocholithiasis is diagnosed by intraoperative cholangiography (IOC) during lap CHE and biliary decompression is required, anterograde stent placement via the cystic duct may be a rescue maneuver avoiding the necessity of intraoperative ERC.

Methods: Case report of a patient with extensive cholecysto- and choledocholithiasis diagnosed by IOC during lap CHE.

Results: An 85 years old female patient admitted with acute onset of abdominal pain and cholestasis diagnosed by blood test. Preoperative ultrasound revealed a moderately widened common bile duct (CBD) of 9mm. The patient was taken to the operating room to perform lap CHE. IOC revealed a large prepapillary biliary stone of 15 mm with widened CBD proximally (Fig. 1). Laparoscopic biliary stone clearance was not feasible due to the size of the stone. Moreover, intraoperative ERC was not possible due to unavailable ERC resources. Therefore, for biliary decompression, a 10cm, 7 Fr., double-pigtail cholangiocatheter was trans-cystically inserted over a guide-wire into the CBD along the stone and across the papilla into the duodenum (Fig. 2). The procedure was completed by CHE. Postoperatively, cholestasis rapidly improved and the patient was discharged at the third postoperative day. ERCP with stent and stone removal ± lithotripsy will follow in 3 months.

Conclusion: Intraoperative anterograde trans-cystic CBD-stenting is a rescue maneuver to be considered in case of extensive choledocholithiasis and unavailable intraoperative ERC. It should be regarded as a bridging therapy to definitive treatment of choledocholithiasis by ERCP and eventually lithotripsy.

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