Recurrent Choledocholethiasis After Billroth II Gastrectomy: A Combined Endoscopic-Laparoscopic Technique

Li-Yun Zhang, MD, Nikolaus Zuegel, MD, Alain Schmit, MD, Martin Kox, MD

Centre Chirurgical, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg (Drs. Zhang, Zuegel, Kox). Department of Surgery, Ruijin Hospital, University School of Medicine, Shanghai, China (Dr. Zhang). Department of Surgery, Campus Grosshadern LM-University Munich, Germany (Dr. Zuegel). Department of Gastroenterology, Centre Hospitalier Emile Mayrisch, Esch-sur-Alzette, Luxembourg (Dr. Schmit).

ABSTRACT

Background and Objective: After gastrectomy, the incidence of cholelithiasis formation increases. However, as a result of adhesions and reversed anatomy, either the surgery or the endoscopy is technically difficult. The aim of this article was to evaluate whether a combined endoscopic-laparoscopic “rendezvous” technique is effective in eliminating choledocholithiasis after Billroth II gastrectomy.

Methods: We present the case of an 89-year-old Caucasian man who had undergone appendectomy, laparoscopic cholecys- tectomy, and open distal gastrectomy with Billroth II gastrojejunostomy for early gastric cancer. He presented with recurrent choledocholithiasis and no fever or jaundice. Before admission, endoscopic retrograde cholangiopancreatography (ERCP) had been tried two times but was not feasible. Laboratory test findings revealed elevated cholestatic enzymes; magnetic resonance cholangiopancreatography revealed common bile duct stones. A laparoscopy was performed, and adhesions were lysed and jejunostomy was established by laparoscopy. A trocar was inserted and secured with a purse-string suture. The laparoscopically assisted ERCP was then performed.

Results: With the help of the laparoscopy, the papilla was reached successfully. Endoscopic sphincterotomy was performed. Common bile duct stones were extracted by irrigation/suctioning or with the help of a balloon catheter. Cholangiography was done to confirm complete stone clearance. A remarkable improvement was noticed, with normal- ization of liver function indexes. The patient was discharged home on postoperative day 6.

Conclusion: A combined endoscopic-laparoscopic rendezvous technique is an efficient, reliable, and minimally invasive method of treating choledocholithiasis after gastrectomy.

Key Words: Combined endoscopic-laparoscopic technique, Common bile duct stones, Laparoscopically assisted ERCP.

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