Treatment-Associated Disorders

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

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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.)