One-stage fluoroscopic-guided laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy for the treatment of choledocholithiasis after Roux-en-Y reconstruction

Abstract

Patients with a history of gastrectomy have a higher incidence of cholecystocholedocholithiasis and morbidities. In particular, the management of choledocholithiasis with endoscopic retrograde cholangiopancreatography (ERCP) has been challenging in patients after Roux-en-Y or Billroth II reconstruction due to the altered gastrointestinal anatomy. A 92-year-old man presented with high fever. He had undergone laparoscopic distal gastrectomy with Roux-en-Y reconstruction 9 years earlier for gastric cancer. Choledocholithiasis was diagnosed and ERCP was attempted, but cannulation of the papilla of Vater failed. An elective one-stage operation was planned. One-stage fluoroscopic-guided laparoscopic transcystic papillary balloon dilation (LTPBD) and laparoscopic cholecystectomy (LC) were performed. The operation time was 130 min with 3 mL of intraoperative bleeding. The patient was discharged on postoperative day 3 with no complications. We report this case in which one-stage LTPBD and LC was successfully performed for a super-elderly patient with choledocholithiasis after Roux-en-Y reconstruction.

Background

Patients who have undergone gastrectomy are at risk of cholecystocholedocholithiasis (CCL).^1–3 In particular, the presence of a gastrojejunal anastomosis after gastrectomy (such as with Billroth II or Roux-en-Y reconstruction) has traditionally been considered a challenging problem. This is because the success rate of subsequent endoscopic retrograde cholangiopancreatography (ERCP) remains very low, even for experienced endoscopists.^{4 5}

If ERCP failed, treatment options for CCL in such patients include one-stage LCBDE+laparoscopic cholecystectomy (LC), balloon enteroscopy-assisted ERCP or rendezvous ERCP.^{6 7} However, balloon enteroscopy-assisted or rendezvous ERCP needs advanced endoscopic technologies.

Conventionally, LCBDE has been performed using a transductal approach or transcystic extraction of common bile duct stones (CBDs) using choledochoscopy or a T-tube, and may encounter several problems (bile duct stricture, bile leakage, restriction of the diameter of CBDs or cystic duct, etc).^{8 9}

We report a case in which one-stage laparoscopic transcystic papillary balloon dilation (LTPBD) and LC were successfully performed for a super-elderly patient with choledocholithiasis after Roux-en-Y reconstruction.

Case presentation

A 92-year-old man presented with high fever. He had undergone a previous laparoscopic distal gastrectomy with Roux-en-Y reconstruction 9 years earlier to treat gastric cancer (pT1bN1M0 stage IB). No recurrences were identified.

On arrival, the patient was asymptomatic. Vital signs and physical examination showed no untoward features other than high fever (38°C).

Investigations

Blood examination on admission revealed: C reactive protein, 5.03 mg/dL; white cell count, 5.9×10⁹/L; total bilirubin, 2.8 mg/dL; direct bilirubin, 0.7 mg/dL; alkaline phosphatase, 706 IU/L and γ-glutamyltransferase, 392 IU/L. The remaining blood test results were unremarkable.

Contrast-enhanced CT and MR cholangiopancreatography revealed the presence of multiple stones in a thick-walled gallbladder, and choledocholithiasis in a distended CBD (figure 1A, B). ERCP was attempted, but the papilla of Vater was unable to be cannulated due to the altered gastrointestinal anatomy. Clinical symptoms and laboratory findings soon improved with conservative therapy.

Figure 1.

e-CT and MRCP show the presence of multiple stones in a thick-walled gallbladder and choledocholithiasis in a CBD (A) MRCP imaging (arrowhead: multiple stones) (B) e-CT imaging (arrowhead: multiple stones). CBD, common bile duct; MECP, MR cholangiopancreatography.

Elective one-stage surgery (LTPBD and LC) was planned.

Treatment

The procedure was performed under a constant fluoroscopic control area by a team of surgeons and an interventional radiologist. A 4-trocar technique was used for LC (12 mm, 12 mm, 5 mm and 5 mm trocars) (figure 2).

Figure 2.

The placement of 4-trocars and the Britetip sheath introducer (arrowhead: Britetip sheath introducer).

Intraoperative findings revealed little intra-abdominal adhesion and no recurrence of gastric cancer in the anastomosis site or lymph nodes.

First, a procedure similar to normal LC was performed (serosa of gallbladder section, hepatic floor detachment, dissection of Calot’s triangle and obtaining the critical view of safety).

After clipping the cystic duct on the gallbladder side and cutting the duct halfway around the circumference, a Britetip Sheath Introducer (REF 401–823M; Cordis, Warren, New Jersey, USA) was inserted under the right hypochondriac position percutaneously into the cystic duct (figures 2 and 3A, B) using a flexible Radifocus guidewire (REF RF-GA35153; Terumo Europe NV, Leuven, Belgium). The guidewire was cannulated to the duodenum beyond the papilla of Vater through the CBD.

Figure 3.

(A) Cutting the duct halfway around the circumference (B) inserting a Britetip sheath introducer into the cystic duct.

After contrasting the bile duct from the sheath, and having confirmed the presence of choledocholithiasis, dilation of the papilla of Vater was performed using a balloon catheter (10 mm×40 mm; 7 atm, 3 min, REF 70239000; Tokai Medical Products, Aichi, Japan) (figure 4A).

Figure 4.

(A) Dilation of the papilla of Vater (arrowhead) (B) extruding the stones with a balloon and cleaning the CBD (arrowhead: stones) (C) Pigtail-shaped drainage catheter (arrowhead) for preventing oedema of the papilla of Vater and pancreatitis. CBD, common bile duct.

A Selecon MP Catheter (REF CB-V68ST20; Terumo Europe NV, Leuven, Belgium) was inflated upstream of the choledocholithiasis. We extruded the stones with a balloon and then cleaned the CBD (figure 4B). This procedure was repeated three times.

After cleaning the CBD, absence of any residual stone was confirmed from a final cholangiogram and a pigtail-shaped drainage catheter (REF CCL2-0850HB; UreSil, Skokie, Illinois, USA) was placed at the papilla of Vater to prevent oedema of the papilla of Vater and pancreatitis (figure 4C). This drainage catheter easily fell into the duodenum at the start of a meal. We removed the balloon catheter system, closed the cystic duct with clips, and retrieved the gallbladder in the usual manner.

The procedure was performed under the fluoroscopic control area by an interventional radiologist. The operation time was 130 min, with 3 mL of intraoperative bleeding.

Outcome and follow-up

The postoperative course was good, with no complications. The patient was discharged on postoperative day 3.

Discussion

Patients with a history of gastrectomy show a higher incidence of CCL and morbidities requiring surgical treatment.^1–3 Akatsu et al reported that 102 of 805 patients (12.7%) after gastrectomy for gastric cancer developed gallstones and 4 patients (0.5%) developed choledocholithiasis. In their study, 3 of 295 patients (1.0%) with Roux-en-Y reconstruction developed choledocholithiasis.¹

The management of choledocholithiasis by ERCP in patients after Roux-en-Y or Billroth II reconstruction has been challenging, due to the altered gastrointestinal anatomy.¹⁰ If ERCP failed, treatment options for CCL in such patients include one-stage laparoscopic common bile duct (CBD) exploration (LCBDE)+LC, balloon enteroscopy-assisted ERCP or rendezvous ERCP.

Some reports have described the safety and effectiveness of balloon enteroscopy-assisted or rendezvous ERCP for these patents.^{6 7} However, these techniques need either the cooperation of well-experienced endoscopists or advanced medical equipment, and relatively few hospitals meet such conditions.

Few studies have examined treatment strategies for CCL patients with a history of gastrectomy.^{4 5} Zhang et al stated that ERCP+LC seems attractive for treating CCL in patients with a history of Billroth I gastrectomy, whereas LCBDE+LC appears better suited to patients with a history of Billroth II or Roux-en-Y esophagojejunostomy.⁴ In that study, the success rate of ERCP for CBD stone clearance was 81.2% in patients with a history of Billroth I gastrectomy, but only 23.7% in patients with a history of non-Billroth I gastrectomy.

Kim et al reported the advantage of a one-stage approach for the management of CBDs after gastrectomy and noted that laparoscopic exploration should be the initial approach for gastrectomy patients with CBD stones.⁵ In their study, to clear CBD stones, ERCP was attempted before LC in eight patients with previous gastrectomy, but proved successful in only one patient (12.5%). Conversely, duct clearance was successful in all patients who underwent surgical CBDE (LCBDE or CBDE).

Past studies have confirmed the advantages of a one-stage approach for the management of CBDs after gastrectomy, but conventional LCBDE (transductal or transcystic using a T-tube or choledochoscopy) is associated with various complications, including bile duct stricture, bile leakage, prolonged biliary fistula, bleeding and possible peritonitis following removal of the T-tube. In addition, the procedure places restrictions on the size and diameter of CBDs or cystic ducts that can be treated.^11–13 Furthermore, history of gastrectomy represents a risk factor for severe intra-abdominal adhesions around the hepatoduodenal ligament. Severe adhesions around the hepatoduodenal ligament prevent smooth LCBDE with a transductal approach.

In our case, one-stage LTPBD and LC was successfully performed for a super-elderly patient with choledocholithiasis after Roux-en-Y reconstruction.

Our novel method had several interesting features. One of the principal advantages of this approach is the preservation of the CBD and papillary function. Biliary complications such as bile leakage and biliary stricture can become a major problem for patients who undergo LCBDE by choledochotomy.⁹ LTPBD does not require incision of the CBD or papilla of Vater or insertion of a T-tube, and can be considered to reduce the biliary complications.

Another advantage is the low invasiveness and short hospital stay required. Given this advantage, the method we described might be feasible for elderly individuals with complicated comorbidities.

The perioperative and postoperative course (operation time, 130 min; intraoperative bleeding, 3 mL and postoperative hospital stay, 3 days) were similar to those seen after LC alone.

Several randomised studies have compared the two-stage (ERCP+LC) and one-stage approach (LC+LCBDE or CBDE), showing that the one-stage approach achieved an almost equivalent complication rate, with a comparably shorter hospital stay and relative cost-effectiveness.^{14 15}

Other studies have shown that transcystic LCBDE is associated with a significantly shorter duration of hospitalisation and shorted procedure time than the transductal approach.⁸

In addition, according to the Society of American Gastrointestinal and Endoscopic Surgeons guidelines, transcystic stone clearance may be hampered by large (>6 mm) or numerous (>5) stones.^{11 16–18} However, in this case, even though large stones (>1 cm) and multiple stones (>5) were present, complete CBD clearance was obtained using the transcystic LTPBD procedure.

Additional research and long-term follow-up are needed in the future to determine whether the method of LTPBD and LC is safe and feasible procedure for patients with previous gastrectomy. Furthermore, one limitation of this method is that the cooperation of an experienced interventional radiologist is needed.

In our experience, this method is safe and effective for patients with previous gastrectomy, and further endoscopic or surgical procedures are not needed.

One-stage LTPBD and LC were effective for a patient with previous gastrectomy with CCL. This procedure might offer a useful alternative to a two-stage approach in such patients.

Learning points.

• Patients with a history of gastrectomy show a higher incidence of cholecystocholedocholithiasis (CCL) and morbidities requiring surgical treatment.

• Appropriate management of these patients remains contentious.

• One-stage laparoscopic transcystic papillary balloon dilation and laparoscopic cholecystectomy was effective for a patient with CCL after Roux-en-Y reconstruction.

• This procedure might offer a useful alternative to a two-stage approach in these patients.