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cbd stent in situ

III-effects of stent in-situ should be explained, record should be maintained [8] and patient should be advised regular follow up and stent removal after 6 weeks.

Choledocholithiasis is presence of stone in Common bile duct (CBD) which can be treated by endoscopy or surgery [1]. Retained foreign bodies like stents forms a nidus for stone formation resulting in pain, fever, jaundice.

Choledocholithiasis is evident in approximately 10–15% patients with gallstones, more commonly secondary. However primary common bile duct (CBD) stones are more common in Asia. Choledocholithiasis can be treated by endoscopy or surgery [1] . Recent trend is to do ERCP primarily and stone extraction with or without CBD stenting. If not removed within time (4–6 weeks), Stent can act as a nidus for stone formation [2] , [3] . Here we discuss a case of Choledocholithiasis in a forgotten biliary stent (∼8.5 years).

Conclusion

Stents may remain without complications or may migrate, and rarely form nidus for stone formation. If kept for long time they lead to bacterial proliferation, biofilm formation and precipitation of calcium bilirubinate presenting as fever, pain, jaundice. Stent-stone complex can be treated endoscopically and surgically [6,7]. As stent can cause stone formation, infection and other complications, timely removal of stent should advised.

Our patient, a 60 years old female, presented with pain in abdomen since 8 days with nonbillious vomiting and low grade fever. Past history was suggestive of obstructive jaundice in 2007. CT abdomen (2007) suggested benign stricture in lower CBD but no gallstones, brush cytology was negative for malignant cells. Patient underwent ERCP, sphincterotomy with CBD stenting on 2/8/2007. Patient was advised follow up for stent removal after one month. Patient did not go for stent removal as she had no complaints.

Case presentation

60 years female patient admitted in surgery ward with features of cholangitis with computed tomography showing cholangitic abscess with dilated common bile duct and sludge around stent in situ. Stone was found at proximal end of stent during surgery.

She remained asymptomatic for about 8.5 years. In Feb, 2016 (after 102 months), she presented with fever, abdominal pain and vomiting. On examination, patient was vitally stable with minimal tenderness in right hypochondrium. Blood profile was normal. Abdominal ultrasound revealed 8 mm calculus in gall bladder. Upper gastrointestinal endoscopy revealed grade B esophagitis with discoloured CBD stent in-situ. Endoscopic stent removal was unsuccessful. CECT abdomen ( Fig. 2 ) suggested cholangitic abscesses in both lobes of liver along the biliary system with cholecystitis with 2 cm dilated CBD and hyperdense sludge around the stent. MRCP showed dilated intrahepatic biliary radicles with CBD stent in situ with sludge around with multiple cholangitic abscesses. Patient was planned for open cholecystectomy and CBD exploration. Though laparoscopy has advantages over open method [4] , open surgery was chosen due to diagnostic dilemma (calculus with sludge around stent) and considering difficulty in dissection. On exploration, cholecystectomy was done. Gallbladder was oedematous and friable. CBD explored, stone was found at proximal end of CBD stent giving a lollipop like appearance to the stent-stone complex ( Fig. 1 ). Stent -stone complex was removed along with sludge. CBD clearance was done and patency of distal end into duodenum confirmed by passing Bakes’ dilators. T-tube (14 Fr) kept and incision over CBD closed. Postoperative course was uneventful. T-tube cholangiogram was done on postoperative day 10 which showed contrast entering in duodenum. T-tube was removed on day 10. Patient was followed up every month till now. Presently, patient has no complaints.

Cbd stent in situ

The experience of our first hundred patients where an antegrade biliary stent had been used as an adjunct to CBD closure has been encouraging. There has been no conversion or mortality. The incidence and complication has been minimal [ Table 5 ].

In patients with a strong suspicion of CBD stones on clinical and biochemical indicators, not otherwise documented by preoperative sonogram (in most of the cases) or magnetic resonance cholangiopancreatography (MRCP) (in a selected few), we prefer to perform a per-operative cholangiogram (POC). MRCP was done only in selected patients in our series due to financial constraints. In 69 patients who underwent POC, 52 patients were found to have a CBD stone and underwent subsequent LCBDE with LC.

Break up endoscopic retrograde cholangiopancreatography group

The series included 318 female and 116 male patients. The majority of the patients (210) belonged to the age group between 40 and 60 years, followed by the age groups 20-40 years (133) and 60-80 years (107). Only 14 patients were aged less than 14 years. The commonest presentation was abdominal pain, either in the epigastrium or the right hypochondrium (50.5%). A history of jaundice or icterus at presentation was found in 35.19% of the patients, whereas 21% of patients had a history of prior hospitalization due to acute pain in abdomen and a conservative management. There is a fixed institutional protocol that is implemented while treating patients with choledocholithiasis [ Table 1 ].

DISCUSSION

LCBDE performed via choledochotomy directly. Transcystic LCBDE was avoided because of inherent limitations and possible contraindications / complications [ Table 4 ]

Following the principles of open surgery, a surgeon has multiple options regarding the management of choledochotomy following LCBDE:

The cystic duct was then divided and the gallbladder was then lifted up from the liver bed and removed with the extracted stones in an endobag. Hemostasis was secured, a subhepatic drain was placed and the abdomen was deflated.

Conclusion:

Endoscopic CBD clearance following an endoscopic sphincterotomy gained popularity as a means to tackle choledocholithiasis with cholelithiasis. The introduction of laparoscopy in treating choledocholithiasis as a single stage treatment raised an important issue – how to choose the treatment for each particular patient.

Report of an animal study published earlier[28] led us to conceptualize closure of the CBD over an antegrade biliary stent. The first report of laparoscopic primary closure of the CBD had come from Lange V and his team.[29] We had started performing choledochoscopies followed by antegrade biliary stenting by then. The initial experiences (8 patients – 5 female and 3 male) over a 3-month period were encouraging and we persisted with the technique.