Case 15

Dictated by Donald E. Wenner, MD FACS

59 YO M presented with gall stone pancreatitis. Lab findings were bili 3.0, SGOT 290, SGPT 211, Alk Phos 128, and Amylase 977. Patient was admitted, made NPO, hydrated and given analgesics. The epigastric pain subsided rapidly, and the following day the amylase was down to 411. The patient was taken to surgery for LC with IOC. The cholangiogram showed non dilated biliary tree, and an apparent filling defect in the ampulla, just beyond the the confluence of the CBD and pancreatic duct. The patient was given glucagon, the duct was flushed, and the Arrow balloon cholangiocatheter would readily traverse the ampulla and enter the duodenum. A second cholangiogram was obtained after these maneuvers, and the appearance of the ampulla was unchanged. The 2.8 mm choledochoscope was guided via the MIG into the cystic ductotomy and advanced into the CBD. The Ampulla was clearly seen, and there was no stone. The choledochoscope was advanced with minimal effort through the Ampulla, and the characteristic villi of the duodenum were identified. The choledochoscope was withdrawn through the Ampulla back into the CBD. An excellent view was again obtained, and no stone or abnormality was seen. The choledochoscope was removed, the cystic duct clipped, and the gall bladder removed in standard fashion. The amylase the following day was 124. No drains were placed and the recovery was uneventful with the patient requesting discharge on POD # 1.

I sure felt better about this case having visualized the Ampulla, having passed the choledochoscope through it, and knowing I was not leaving a problem stone in the Ampulla. Total operative time was 101 min.