A 74-year-old man presented with generalized itching and mild jaundice. A year earlier, he had undergone a laparoscopic cholecystectomy.
Case 1 Postcholecystectomy Obstruction A 74-year-old man presented with generalized itching and mild jaundice. A year earlier, he had undergone a laparoscopic cholecystectomy. Laboratory test results included total bilirubin, 4.2 mg/dL; direct bilirubin, 3.6 mg/dL; alkaline phosphatase, 503 IU/L; aspartate aminotransferase, 841 IU/L; and alanine aminotransferase, 561 IU/L. Serum immunoelectrophoresis showed diffuse hyperglobulinemia; the IgG level was 2220 mg/dL. The level of tumor marker CA19-9 was elevated to 550 U/L as a result of chronic cholangitis. Findings of a CT scan of the abdomen were normal. Endoscopic retrograde cholangiopancreatography showed a surgical clip obstructing the common biliary tract. Residual stones are the leading cause of biliary obstruction; they occur in up to 2% of post-laparoscopic cholecystectomy patients. The clip was surgically removed; the patient's clinical and laboratory findings gradually improved after the operation. There has been no recurrence of biliary obstruction 1 year after clip removal. Minimally invasive laparoscopic cholecystectomy generally is associated with a shorter hospital stay, fewer complications, less trauma, and a lower incidence of cardiac and respiratory complications than open cholecystectomy.1-5 It is therefore often the procedure of choice for patients who are at high operative risk, such as elderly persons and those with cardiac and respiratory disease.2,6 Jaundice occurs rarely after the laparoscopic procedure.7 However, an increased incidence of common bile duct or hepatic duct injury exists with laparoscopic cholecystectomy. 2,4 Furthermore, these bile duct injuries tend to be higher in the duct system and more extensive than those that occur in traditional cholecystectomy; thus, the likelihood of successful reconstruction is reduced.8
REFERENCES:1. McMahon AJ, Russell IT, Baxter JN, et al. Laparoscopic versus minilaparotomy cholecystectomy: a randomized trial. Lancet. 1994;343:135-138. 2.Hannan EL, Imperato PJ, Nenner RP, Starr H. Laparoscopic and open cholecystectomy in New York State: mortality, complications, and choice of procedure. Surgery. 1999;125:223-231. 3. Peterli R, Schuppisser JR, Herzog U, et al. Prevalence of postcholecystectomy symptoms: 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 laparoscopic cholecystectomies. N Engl J Med. 1991;324:1073-1078. 5. Holohan TV. Laparoscopic cholecystectomy. Lancet. 1991;338:801-803. 6. Dubois F, Berthelot G, Levard H. Laparoscopic cholecystectomy: historic perspective and personal experience. Surg Laparosc Endosc. 1991;1:52-57. 7. Niranjan B, Chumber S, Kriplani AK. Symptomatic outcome after laparoscopic cholecystectomy. Trop Gastroenterol. 2000;21:144-148. 8. Branum G, Schmitt C, Baillie J, et al. Management of major biliary complications after laparoscopic cholecystectomy. Ann Surg. 1993; (Case and photograph courtesy of Drs K. Haritos and N. Akritidis.)