|Year : 2016 | Volume
| Issue : 1 | Page : 21-23
Laparoscopic cholecystostomy in treatment of obstructive jaundice
Zijah Rifatbegovic, Amra Mestric, Zlatan Mehmedovic
Department of Surgery, University Clinical Center, Tuzla, Bosnia and Herzegovina
|Date of Submission||27-Jan-2016|
|Date of Acceptance||26-Feb-2016|
|Date of Web Publication||1-Apr-2016|
Department of Surgery, University Clinical Center, Trnovac bb, 75000 Tuzla
Bosnia and Herzegovina
Source of Support: None, Conflict of Interest: None
Cholecystostomy is considered to be a treatment option when conservative treatment of acute cholecystitis failed in elderly and critically ill patients. The aim of this paper is to present a cholecystostomy in the treatment of obstructive jaundice before the definitive operation for the underlying cause of jaundice. The patient in poor general condition with the obstructive jaundice was diagnosed to have a pancreatic head tumor. He had undergone the laparoscopic cholecystostomy. After improvement of the general condition and lower total bilirubin level, the patient had undergone to definitive procedure. It is shown that laparoscopic cholecystostomy can be a successful way for adequate bile drainage in a patient with poor general condition before the definitive treatment of obstructive jaundice.
Keywords: Obstructive jaundice, laparoscopic cholecystostomy, pancreatic head tumor
|How to cite this article:|
Rifatbegovic Z, Mestric A, Mehmedovic Z. Laparoscopic cholecystostomy in treatment of obstructive jaundice. Transl Surg 2016;1:21-3
| Introduction|| |
In high-risk patients with acute calculous cholecystitis, percutaneous cholecystostomy can serve as a bridging option to cholecystectomy or as definitive treatment. However, tube dislodgement, tube blockage, and bleeding are described. Laparoscopic drainage procedures have been widely used in abdominal surgery due to better control and less complications than percutaneous procedures. Laparoscopic cholecystostomy for acute cholecystitis has been used for over 25 years, but it is rarely described as the first step in obstructive jaundice treatment. The level of bilirubin is decreased and liver function is greatly improved after bile duct drainage by the laparoscopic cholecystostomy. Through this procedure, the goal of optimizing patient's condition is accomplished.
| Case Report|| |
A 72-year-old man presented to the Department of Surgery with weakness, jaundice, and pale stool. He was diagnostically evaluated in the Department of Gastroenterology. The abdominal computed tomography revealed a pancreatic head tumor incorporating the common bile duct. The tumor appeared to be resectable as there was no major blood vessels invasion. The laboratory tests revealed an elevated total bilirubin level of 151.9 µmol/L (normal 3–19 µmol/L), direct fraction 118.5 µmol/L (normal 0–5 µmol/L), and indirect fraction 33.4 µmol/L (normal 0–14 µmol/L). For the past 3 years, the patient had been treated for hypertension. Two years before admission, he had an ischemic stroke event and myocardial infarction.
Due to the high bilirubin level and poor general condition, we decided to decompress the bile duct system and provide an output for biliary drainage. After the usual patient preparation, the pneumoperitoneum was made and laparoscopic inspection revealed a distended gallbladder. Conventional laparoscopic rigid instruments were used. Through the work instrument port, we made a needle puncture through the gallbladder wall. A 5 mm diameter silicone tube with a securing cuff was placed in the gallbladder lumen [Figure 1]. Laparoscopic stitches were placed on the gallbladder wall. One more drain was placed subhepatically. The procedure took 50 min. The postoperative course went without any complications. Postoperative abdominal ultrasonography revealed no signs of intra-abdominal fluid, and laboratory tests revealed lower bilirubin level. The patient was discharged to home with a drain bile secretion of about 200 mL per day [Figure 2]. Two weeks after the cholecystostomy was performed, the patient was again hospitalized. Laboratory tests revealed normal values for the total bilirubin level. The radical procedure pancreaticoduodenectomy with cholecystectomy was performed, and the patient was discharged 10 days after surgery without any signs of biliary fistula [Figure 3].
| Discussion|| |
Malignant obstructive jaundice comprises a group of diseases that can be caused by primary biliary and extra-biliary carcinomas. Generally, surgical resection is the primary treatment for malignant obstructive jaundice; however, for patients who are unable to undergo surgery, urgent treatment is first required to improve hepatic function.
Percutaneous cholecystostomy is a procedure used in a treatment of acute cholecystitis in critically ill patients.
Tube dislodgement, tube blockage, and intra-abdominal bleeding after percutaneous cholecystostomy have been described. Treatment failures after percutaneous cholecystostomy have been described, where repeated percutaneous cholecystostomy or emergent cholecystectomy was required. In a series of cases of percutaneous cholecystostomy, the total 30-day mortality was 17%, and indication-related mortality was 10%. The primary complications associated with percutaneous drainage and stenting include drainage tube or biliary stent dislocation, cholangitis, hemobilia, and pancreatitis.
The laparoscopic approach for obstructive jaundice can be used as a treatment for choledochal cysts and in creating a cholecystojejunostomy to optimize the quality of life in cases of unresectable periampullary carcinoma. Amelioration of symptoms, such as abdominal pain and jaundice, was achieved in all patients in one study after laparoscopic cholecystostomy. In another case of posttraumatic bile duct stenosis, a drainage tube was inserted by laparoscopic cholecystostomy. After temporary bile drainage and a cholecystoenteric bypass, the patient recovered.
We present the case report of the patient with the resectable pancreatic head tumor who presented with poor general condition and high level of total bilirubin. The laparoscopic approach for cholecystostomy is minimally invasive, but it requires adequate equipment and a surgeon skilled in laparoscopic procedures. A 5 mm silicone tube with a securing cuff was used to prevent the tube dislodgement and biliary leakage. No intra-abdominal adhesions on the second radical procedure were observed. We decided on laparoscopic and not percutaneous cholecystostomy as the laparoscopic approach offers a better way of fixing the tube and the opportunity for simultaneous abdominal cavity laparoscopic exploration. We believed that laparoscopic cholecystostomy could be considered a temporary treatment of obstructive jaundice.
The laparoscopic approach using a silicone tube with the balloon results in bile duct decompression without biliary leakage. The procedure is useful in patients with resectable tumors and high bilirubin levels to optimize the patient's condition and to secure the optimal time for the definitive procedure.
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Conflicts of interest
There are no conflicts of interest.
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[Figure 1], [Figure 2], [Figure 3]