Websurg, e-Surgery 關於腹腔鏡手術

Clinical Case

LEAK POST-CBD EXPLORATION

D Fölscher, MD, PhD, Hôpitaux Universitaires de Strasbourg, Strasbourg, France

1. Summary

Laparoscopic CBD exploration is an acceptable modality in the management of choledocholithiasis. This approach is not without potential complications however as is illustrated in this clinical case.

2. Patient

47-year-old woman

3. Past medical and surgical history

Chronic calcific pancreatitis diagnosed 7 years ago, quiescent since then.
No significant past surgical history.

4. History of present illness

The patient presents with a 48-hour history of right upper quadrant abdominal pain, nausea and vomiting.
Her family noted she had recently become increasingly jaundiced.
The patient denies fever or constitutional symptoms.

5. Physical examination

Right upper quadrant tenderness with mild voluntary guarding.
No peritoneal signs.
Remainder of physical exam unremarkable.

6. Relevant laboratory values

AST: 1004 UI/L (9-29)
ALT: 1256 UI/L (8-38)
Tot Bili: 40 mmol/l (3.4-20.5)
Conj Bili: 28 mmol/l (1.7-13.7)
Alk Phos: 134 UI/L (41-117)
Amylase: 53 UI/L (25-108)
CRP: 37 UI/L (<10)
WBC: 9.5 10*3/mm3 (4.0-10.0)

7. Quizzes

7.1. Quiz 1

Which of the following is a likely diagnosis at this stage?
1) Obstruction of the common bile duct secondary to progression of chronic pancreatitis
2) Biliary obstruction secondary to a pancreatic pseudocyst
3) Common bile duct stone migration
4) Choledochal cyst
Correct answers:
1) Obstruction of the common bile duct secondary to progression of chronic pancreatitis
Chronic pancreatitis can evolve to cause CBD stricture in its intrapancreatic portion. This is a possible cause of jaundice in this patient, but it usually develops over time and results in more severe bilirubin elevations.
Reference:
Littenberg G, Afroudakis A, Kaplowitz N. Common bile duct stenosis from chronic pancreatitis: a clinical and pathologic spectrum. Medicine (Baltimore) 1979;6:385-412.
3) Common bile duct stone migration
Ductal stones commonly cause elevation in direct bilirubin associated with pain and colic, but elevation of the transaminases is usually mild while alkaline phosphates is usually markedly elevated. The rapid onset of jaundice makes this a likely choice in the differential diagnosis.
Wrong answers:
2) Biliary obstruction secondary to a pancreatic pseudocyst
Pseudocysts are unlikely to develop after a long period of acquiescent pancreatitis as is the case in this patient. The jaundice would also have developed over a longer time period.
Reference:
Littenberg G, Afroudakis A, Kaplowitz N. Common bile duct stenosis from chronic pancreatitis: a clinical and pathologic spectrum. Medicine (Baltimore) 1979;6:385-412.
4) Choledochal cyst
Adult choledochal cysts commonly present with recurrent bouts of cholangitis and jaundice. However, there is usually marked elevation of bilirubin and alkaline phosphatase compared to the transaminases. The incidence is also low – fewer than 1 in 50,000 live births.
Reference:
Littenberg G, Afroudakis A, Kaplowitz N. Common bile duct stenosis from chronic pancreatitis: a clinical and pathologic spectrum. Medicine (Baltimore) 1979;6:385-412.

8. Examinations

8.1. Ultrasonography

Significantly dilated CBD (>1 cm). No definite stone visualized in CBD.
Multiple stones in gallbladder with a normal GB wall. No ultrasound Murphy's sign.
Evidence of chronic pancreatitis with duct of Wirsung dilatation.

Figure 8.1.a

Figure 8.1.b

8.2. CT scan

Dilated CBD with no stones visualized.
Distended gallbladder.
Diffuse calcifications of the pancreas.
Dilated pancreatic duct.

Figure 8.2.a

Figure 8.2.b

8.3. MRCP

Single stone in distal CBD

Figure 8.3

9. Clinical progression

During the course of the above workup the patient remains afebrile but becomes progressively more jaundiced with a confirmed rise in bilirubin level.

10. Procedure

The patient is taken to the operating room where she undergoes a laparoscopic cholecystectomy and a laparoscopic CBD exploration.
Please watch the following video illustrating the procedure as further questions pertaining to the management of this patient will follow based on it.
video

Video 10

11. Quiz

Having seen the video, at this point would you perform:
1) Primary closure without T-tube drainage
2) Closure over a T-tube
3) Placement of a transcystic drain
4) Roux-en-Y choledocho-jejunostomy
Correct answers:
2) Closure over a T-tube
Due to the chronic pancreatitis, the correct response is to close over a T-tube in case the CBD dilatation is not purely due to the CBD lithiasis but also partially secondary to the chronic process in the pancreas.
4) Roux-en-Y choledocho-jejunostomy
This is necessary in case the dilatation of the biliary tree is secondary to the chronic pancreatitis.
Wrong answers:
1) Primary closure without T-tube drainage
Due to the chronic pancreatitis, the correct response is to close over a T-tube in case the CBD dilatation is not purely due to the CBD lithiasis but also partially secondary to the chronic process in the pancreas.
3) Placement of a transcystic drain
Placement of a transcystic drain could also be considered in this setting although a T-tube is a safer alternative.

12. Procedure

At the time, the surgeon performing the procedure chose a primary closure without T-tube drainage. The intraoperative cholangiogram had demonstrated, in his opinion, adequate passage of dye into the duodenum.
Please watch the brief video as a question will follow based on its contents.
video

Video 12

13. Quiz

Having seen the video, at this point would you:
1) Place a subhepatic drain
2) No subhepatic drain
Correct answer:
1) Place a subhepatic drain
Placement of a subhepatic drain is indicated when a risk of bile leakage exists in the immediate postoperative period. We routinely place such drains after CBD exploration. They may help drain postoperative collections and convert a postoperative bile leak into a drained fistula.
Wrong answer:
2) No subhepatic drain
Placement of a subhepatic drain is indicated when a risk of bile leakage exists in the immediate postoperative period. We routinely place such drains after CBD exploration. They may help drain postoperative collections and convert a postoperative bile leak into a drained fistula.

14. Clinical progression and quiz 1

A subhepatic drain is placed. Postoperatively, the patient is doing very well clinically, tolerating clear liquids with no fever and a benign abdominal exam. The drainage in the subhepatic drain is serous and benign. She has good pain control.

How would you manage this patient now?
1) Early discharge with the drain in place
2) Remove drain and discharge patient
3) Keep patient in hospital for further observation
Correct answer:
3) Keep patient in hospital for further observation
We feel this is the safest course of action.
Wrong answers:
1) Early discharge with the drain in place
Laparoscopic CBD exploration, while associated with reduced morbidity and a shorter hospital stay is not fully equivalent to an uneventful postoperative course as would be expected in a routine cholecystectomy. An early discharge following choledochotomy and laparoscopic CBD exploration could place the patient at risk. However, there is no consensus on the appropriate period of observation necessary in this setting.
2) Remove drain and discharge patient
Laparoscopic CBD exploration, while associated with reduced morbidity and a shorter hospital stay is not fully equivalent to an uneventful postoperative course as would be expected in a routine cholecystectomy. An early discharge following choledochotomy and laparoscopic CBD exploration could place the patient at risk. However, there is no consensus on the appropriate period of observation necessary in this setting. Early removal of the drain adds further risk as many bile leaks will not become manifest for 48 hours or more.

15. Clinical progression and quiz 2

On postoperative day 3, the patient develops abdominal pain, tenderness, fever and an ileus.
Bile is now present in the subhepatic drain (400 cc).

How would you manage this patient now?
1) Antibiotics and supportive care
2) Naso-biliary drain placement
3) ERCP + sphincterotomy
4) Reoperation
Correct answer:
4) Reoperation
This solution is the safest approach. Laparoscopy permits drainage of the bile collection, good peritoneal lavage and direct control of the site of leakage in selected situations.
Wrong answers:
1) Antibiotics and supportive care
A wait and see approach is contraindicated considering the large volume of bile drainage and the septic state of the patient.
2) Naso-biliary drain placement
While endoscopic naso-biliary drainage may help in cases of cystic duct stump leak or edema of the papilla, the leak in this case is likely to be from the CBD suture line and a naso-biliary drain is not appropriate in this setting.
3) ERCP + sphincterotomy
This option is the most commonly used treatment of bile leaks following cholecystectomy. Because of the recent CBD exploration, the volume of biliary drainage and the biliary peritonitis, it is not felt to be an appropriate option at this point.

16. Reoperation

Laparoscopic exploration reveals biliary peritonitis with significant inflammatory adhesions in the right upper quadrant. A decision to convert to laparotomy is taken.
An open subcostal laparotomy reveals a leak from the distal end of the suture line. This is repaired over a T-tube, the abdomen is irrigated thoroughly and the incision is closed.

Figure 16

Video 16

17. Discussion

This case reveals some of the pitfalls of laparoscopic CBD exploration. Primary closure without T-tube drainage is beneficial for the patient by reducing the morbidity associated with the drain itself but should be reserved for the ideal candidates under ideal conditions (no inflammation, infection or intraoperative difficulties).
In this case, the presence of chronic pancreatitis along with pancreatic ductal dilatation should have raised flags about possible outflow obstruction of the CBD secondary to the pancreatic process.

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