Dictated by Donald E. Wenner, MD FACS
30 YO female 1 day after childbirth presented with RUQ abdominal pain and positive Murphy’s sign. Lab data showed a bili of l.0, SGOT of 93, SGPT of 91, alk. phos of 194, and amylase of 40. WBC was 8300. The patient had known gall stones that had been documented by ultrasound during pregnancy. She gave a past history consistent with six years of biliary colic that had never been investigated prior to her most recent pregnancy. Her exam was consistent with acute cholecystitis, and the decision was made to take her to surgery for LC with IOC. At surgery, her cholangiogram showed a reverse meniscus sign, and no flow of contrast into the duodenum. The cystic duct was fairly large and the choledochoscope was guided into the cystic ductotomy with the MIG. Choledochoscopy demonstrated a large stone impacted in the Ampulla of Vater. The stone was readily engaged with the 120 cm x `1.9 Fr. tipless Nitinol stone basket. The stone however could not be retrieved through the cystic duct as it was simply too large. Whether the had grown while in the CBD or had an irregular shape that could have traversed the cystic duct in only one orientation is unknown to me, but two attempts trying to pull it out of the cystic duct failed.
I was left with the choice of breaking it with the laser lithotripter and retrieving the fragments, or proceeding with a choledochotomy approach. Since the cystic duct approach is so great from the standpoint on not requiring a T-tube or sewing, I chose the trans cystic duct laser lithotripsy approach. The laser fiber was threaded down the working channel of the choledochoscope, and the stone broken into three pieces. The largest was retrieved through the cystic ductotomy using the stone basket, and the two smaller fragments washed through the Ampulla. The Ampulla was wide open, and the choledochoscope was easily pushed across the Ampulla into the duodenum. A post clearance cholangiogram showed a normal caliber CBD, and good flow into the duodenum with no filling defects.
The patient recovered from surgery much like a routine lap chole. The amylase the next day was normal at 39. This young mother was sent home feeling well on POD # 1. Young patients as in this example are at higher risk of developing severe pancreatitis after ERCP than are older patients.