Laparoscopic Antegrade Biliary Stenting to Guide Biliary Cannulation in Postoperative ERCP for Ductal Stone Clearance

Abstract

Purpose: The success rate of biliary cannulation is high but still not perfect in endoscopic retrograde cholangiopancreatography (ERCP). Options in these cases have traditionally included percutaneous access, open surgical intervention, and more recently a combination of either percutaneous biliary access or endoscopic ultrasonography with ERCP approach (i.e., rendezvous procedure). A laparoscopic antegrade biliary stenting has been described for biliary stone clearance. We are reporting a case that used antegrade biliary stenting during laparoscopic cholecystectomy to assist in endoscopic biliary access after a failed ERCP. Case history: The patient is a 69-year-old female who presented with worsening intermittent right upper quadrant abdominal pain for 3 weeks. The work up showed that her AST 89 (UL), ALT 277 (UL), Alkaline Phosphatase 278 (UL), and bilirubin of 1 (mg/dL). Abdominal ultrasound showed dilated common bile duct (CBD) to 12 mm and multiple gallstones. The patient underwent outpatient ERCP. The papilla looked traumatized. Cannulation was unsuccessful using sphinctertome and needle-knife. She came to ER 3 days later prior to her scheduled cholecystectomy with increased abdominal pain and elevated bilirubin. A standard cholecystectomy was performed laparoscopically. Intra-operatively, a biliary balloon catheter (Karlan balloon catheter: 4 French, 60 cm) was inserted into the cystic duct and cholangiogram was performed. The CBD was found to be dilated with large stone impacted at the ampulla. Using balloon sweep a dozen of very small stones were removed through the cystic duct, however, the large stone could not be removed. Attempt to pass basket was unsuccessful due to stricture within the cystic duct. The catheter was passed down through the cystic duct and CBD into the duodenum and the position was confirmed with fluoroscopy. This catheter was then cut at the cystic duct and left in CBD. Three clips were then placed proximally on the cystic duct and the gallbladder was then resected. Next day an ERCP was performed. The catheter was seen traversing the ampulla to duodenum. A sphinctertome with guide wire was used and the CBD was easily cannulated alongside Karlan cathter. A large sphincterotomy was performed. 1 cm biliary stone was then extracted from CBD using extraction balloon catheter. The Karlan catheter was then retrieved using a snare. The patient was discharged the following day. Conclusion: Antegrade biliary stenting during lapascopic cholecystectomy provides a guide for subsequent endoscopic biliary access and stone removal, minimzing the risks of a repeated endoscopic failure or the need for percutaneous or EUS-guided rendezvous cannulation.