Dictated by Donald E. Wenner, MD FACS
Patient was a 19 yo female with a bilirubin of four, elevated LFT’s and a thick walled GB with stones. A cholangiogram showed ten stones in the CBD, one impacted at the ampulla, and no flow of dye into the duodenum. Multiple stones in both the CHD and CBD and the impacted stone made a cystic duct approach untenable. A choledochotomy was made and a balloon catheter readily dislodged eight of the stones. The balloon catheter would not traverse the ampulla in spite of multiple tries. The MIG with the choledochoscope and balloon catheter was inserted. The choledochoscope visualized the impacted stone, but it was tightly impacted and the balloon catheter would not pass beyond the stone. I connected both the choledochoscope and balloon catheter to pressure irrigation bags, and advanced the Homium laser 200 micron fiber through the working channel of the choledochoscope. Using a 12 watt power setting and 151 pulses from the laser I was able to break up the tightly impacted stone, and could pass the balloon catheter through the ampulla into the duodenum. The bile duct was irrigated and the choledochoscope directed through the MIG was used to inspect the proximal and distal bile ducts. One additional stone was visualized in the CHD. This was removed using the balloon catheter. The ampulla was clear, but showed a great deal of inflammation, and the choledochoscope would not traverse it. In this setting with an inflamed ampulla and multiple stones I felt that a t-tube was prudent. I closed the choledochotomy around the t-tube using intra-corporeal suturing techniques. A JP drain was placed. The t-tube cholangiogram at the completion of the case looked good.
This was the first MIG case on which I tried the Homium laser. I thought the laser was easier to use than the electro-hydraulic lithotripter. This case took 2h 25min.
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.