Postcholecystectomy

March 1, 2003

A 74-year-old man presented withgeneralized itching and mild jaundice.A year earlier, he had undergone alaparoscopic cholecystectomy.

A 74-year-old man presented withgeneralized itching and mild jaundice.A year earlier, he had undergone alaparoscopic cholecystectomy.Laboratory test results includedtotal bilirubin, 4.2 mg/dL; direct bilirubin,3.6 mg/dL; alkaline phosphatase,503 IU/L; aspartate aminotransferase,841 IU/L; and alanineaminotransferase, 561 IU/L. Serumimmunoelectrophoresis showed diffusehyperglobulinemia; the IgG levelwas 2220 mg/dL. The level of tumormarker CA19-9 was elevated to 550U/L as a result of chronic cholangitis.Findings of a CT scan of the abdomenwere normal. Endoscopicretrograde cholangiopancreatographyshowed a surgical clip obstructingthe common biliary tract. Residualstones are the leading cause of biliaryobstruction; they occur in up to 2% ofpost-laparoscopic cholecystectomypatients.The clip was surgically removed;the patient's clinical and laboratoryfindings gradually improved after theoperation. There has been no recurrenceof biliary obstruction 1 yearafter clip removal.Minimally invasive laparoscopiccholecystectomy generally is associated with a shorterhospital stay, fewer complications, less trauma, and alower incidence of cardiac and respiratory complicationsthan open cholecystectomy. 1-5 It is therefore often the procedureof choice for patients who are at high operativerisk, such as elderly persons and those with cardiac andrespiratory disease. 2,6 Jaundice occurs rarely after the laparoscopicprocedure. 7 However, an increased incidence of common bileduct or hepatic duct injury exists with laparoscopic cholecystectomy. 2,4 Furthermore, these bile duct injuries tendto be higher in the duct system and more extensive thanthose that occur in traditional cholecystectomy; thus, thelikelihood of successful reconstruction is reduced. 8

References:

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3. Peterli R, Schuppisser JR, Herzog U, et al. Prevalence of postcholecystectomysymptoms: long-term outcome after open versus laparoscopic cholecystectomy.World J Surg. 2000;24:1232-1235.
4. The Southern Surgeons Club. A prospective analysis of 1518 laparoscopiccholecystectomies. N Engl J Med. 1991;324:1073-1078.
5. Holohan TV. Laparoscopic cholecystectomy. Lancet. 1991;338:801-803.
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7. Niranjan B, Chumber S, Kriplani AK. Symptomatic outcome after laparoscopiccholecystectomy. Trop Gastroenterol. 2000;21:144-148.
8. Branum G, Schmitt C, Baillie J, et al. Management of major biliary complicationsafter laparoscopic cholecystectomy. Ann Surg. 1993;217:532-541.