Bestoun Ahmed, MD, FACS, FRCS, Ziad Awad, MD, FACS, Michael Nussbaum, MD, FACS. University of Florida-Jacksonville
We are presenting a Video Abstract of a patient who presented wit a tight Lower common bile duct stricture who underwent multiple failed attempts of ERCP-guided dilations and stents placement. Roux-en-Y Choledochojejunostomy was also not an applicable option secondary to intense abdominal wall and interloop bowel adhesions.
A 41-year-old morbidly obese female patient referred for having an intractable lower CBD stricture. She initially presented 4 years back to the GI service with jaundice and abdominal pain with h/o laparoscopic cholecystectomy. She has been through 6 ERCP-guided dilation sessions with multiple stents placement over 4 years period.
She also has h/o open colon resection for benign disease, open appendectomy through a lower midline approach for ruptured appendix and and multiple incisional Hernias mesh repair.
Celiac block was done on 2 occasions and was on multiple pain medications on chronic bases. ERCP pictures showed a tight benign looking stricture at the lower common bile duct. She underwent Laparoscopic choledochoduodenostomy with smooth postoperative recovery and significant resolution of her pain.
Following intraperitoneal access, Intense adhesions are released from the operative site. Dissection of CBD is performed. There was intense inflammation and scarring of the area. Ultrasound examination and aspiration confirmed the position of the CBD. Following Kocherization of the duodenum, a longitudinal choledochotomy and Duodenotomy incisions are created. Anastomosis is performed using interrupted 3/0 Vicryl sutures.
Operative time was 140 minutes and EBLwas 50 ml. The patient tolerated ambulation on the same day of surgery and discharged in 48 hours. UGI contrast study showed no leak and it clearly opacified the anastomosis. Follow up after 3 months showed significant resolution of pain with no additional symptoms
Laparoscopic Choledochoduodenostomy is still a vaild approach to treat lower Common Bile Duct strictures if Endoscopic and RNY choledochojejunostomy approaches are not options.
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