Case 9

Dictated by Donald E. Wenner, MD FACS

The patient was a 24 yo female with a bili of 2 and moderately elevated LFT’s. The initial cholangiogram failed to get dye into the duodenum, and was suspicious for a stone impacted in the ampulla. I manipulated the balloon cholangiocatheter and with several tries I got it across the ampulla into the duodenum. I repeated the cholangiogram, and it clearly showed a stone impacted in the ampulla outlined by the dye, as well as some flow of dye across the ampulla. With this impacted stone, a cystic duct approach did not look feasible. I performed a choledochotomy and was able to dislodge the stone with the balloon catheter and bring it out through the choledochotomy. I inspected the bile duct proximally and distally with the choledochoscope run through the MIG. The choledochoscope would readily cross the ampulla into the duodenum. I repaired the choledochotomy using a running stitch and intra-corporeal knot tying techniques. The repair was then checked by cannulating the cystic duct and checking it while infusing saline, and by repeating the cholangiogram. The cholecystectomy was completed, and the choledochotomy closure was sprayed with Tisseel fibrin tissue sealant, and a JP drain placed.

Discussion:

Use of the intra-corporeal running suture to close the choledochotomy worked great. I especially liked checking my closure with the saline infusion and the use of the Tisseel as an adjunct to ensure a leak-proof closure of the CBD when closed without a t-tube. This case took 1h 45min.

Young patients such as this have a higher risk of pancreatitis from ERCP/sphincterotomy, and have a long time for ductal hyperplasia to turn into bile duct cancer. We do not know the long term effects from cutting the Sphincter of Oddi.