CLINICAL CASE

A 64-year-old female patient presented with a 6-day history of epigastric pain of insidious onset, colic type of moderate intensity, radiating to the interscapular zone and partially yields with common analgesic intake. Two days before admission, nausea and vomiting of food content on two occasions were added to the symptoms, and 24-hours before admission, change in skin and mucous membrane coloration which gain a yellowish tone were also added, besides choluria and acholia. For patholog- ical history, the patient reported arterial hypertension in regular treatment with 50 mg/day of losartan and denies other base pathologies. For surgical history, she reported a choledochotomy performed 30 years ago by Kocher incision. The ultrasound showed intrahepatic non-dilated bile ducts, and a 10.2mm common bile duct on its proximal portion, with the distal portion not being visible. On admission, the laboratory reported: white blood cells 17,600/µL, neutrophils 76%, hemo- globin 12.3 g/dL, total bilirubin 2.66 mg/dL and direct bilirubin

1.41 mg/dL, alkaline phosphatase 171 U/L, GOT 51 U/L and GPT 71 U/L. Due to laboratory findings, the patient was sub- mitted to a MRCP which showed the common hepatic duct and common bile duct to up to 10 mm, with a 5 mm signal voids compatible with calculi. An ERCP was performed based on the aforementioned findings, in which the duodenal papilla could not be identified, therefore, the extraction of choledocholithiasis was not possible and so surgical therapy was performed: laparoscopic choledochotomy with calculi extraction with a Fogarty balloon, peroperative cholangiography and T-tube placement (see Figure 1). In the peroperative cholangiography, proper contrast passage to the duodenum without residual filling defect’s imagery was recorded. The patient had a favorable postoperative course, beginning oral tolerance within the first postoperative day (POD1). Within the POD5 a T-tube cholan- giogram was performed, in which proper contrast passage to the duodenum was recorded, without evidence of leaking or signs of signal voids suggesting residual calculi (see Figure 2). The patient is discharged on the POD6 without complications, good oral tolerance, no spontaneous pain nor infection and it is planned for the T-tube to be extracted within POD45. The extraction of the T-tube was performed after the POD45 and annual controls are performed on the patient without complications up to this date.

Figure 1.  Entrance of the T-tube to the place where the choledochotomy was perfor- med is observed, along with the suture points. 

Figure 2.  T-tube cholangiogram on POD5, no leaks nor filling defects observed on the bileduct. 

DISCUSSION

The presence of choledocholithiasis as a bile pathology is very frequent on our region, with the ERCP being the chosen method upon its presence for the calculi extraction and the prophylactic cholecystectomy within 48-hours after the performed ERCP to avoid future complications. Surgical resolution must proceed when the choledocholithiasis cannot be resolved by an endo- scopic approach⁴, with the choices being the open or laparoscop- ic approach, given that a gold standard for surgical treatment does not exist. Several studies, both regional and international, conclude that choledochotomy and extraction of calculus with or without placement of a T-tube for draining is a safe option of treatment2,4-7 and according to the findings of Yegros-Ortiz et al7 there is no significant difference in the morbi-mortality with or without the placement of the T-tube after the choledochotomy. Canullan et al2 proposes the efficacy superiority of the transcystic approach of extraction over the transcholedocian approach.

In our case the choledochotomy with T-tube placement was decided due to the absence of a previous endoscopic papillotomy, which implicated the placement of a drainage for bile duct de- compression.