PTCD and choledochoscopy for recurrent choledocholithiasis after multiple abdominal surgeries: a case report

Abstract

Background: Special attention should be given to intra-abdominal adhesions in patients with a history of open cholecystectomy for gallstones or abdominal surgery. Choosing the appropriate surgical approach to remove the stones is crucial.

Patient summary: A 68-year-old male was admitted due to sudden onset of upper abdominal pain lasting more than 6 h. In 2018, he underwent open Billroth II surgery for gastric cancer at an external hospital, and in 2020, he underwent open cholecystectomy for gallstones. In August 2023, he received gamma knife treatment for recurrent gastric cancer brain metastasis at another hospital with good results. In December of the same year, the patient presented to our hospital due to recurrent common bile duct stones and cholangitis. Given his history of two abdominal surgeries, percutaneous transhepatic cholangiodrainage (PTCD) combined with choledochoscopic stone extraction was chosen, which was successful in completely removing the stones. A PTCD tube was left in place postoperatively.

Conclusion: For patients with a history of two or more abdominal surgeries who experience recurrent common bile duct stones, PTCD has the advantages of a shorter operative time, less blood loss, earlier postoperative ventilation, earlier resumption of eating, minimal trauma and faster recovery.

Keywords: case report; cholangitis; epigastric pain; gallbladder stones; history of multiple abdominal surgeries; percutaneous transhepatic cholangiodrainage.

Figure 1

(A) Preoperative MRCP image showing the size and location of the common bile duct stone in the patient. (B) Pneumatosis and abdominal adhesion.

Figure 2

(A) Ultrasound guidance used to identify the dilated bile duct and determine the optimal skin entry point for needle insertion. (B) Insertion of a cannula needle (16G) into the dilated bile duct under ultrasound guidance. Aspiration of thick bile confirms correct needle placement within the bile duct. (C) Introduction of a J-tip guidewire through the cannula needle, followed by a controllable active core guidewire to secure access and maintain position within the bile duct. (D) Removal of the cannula needle and insertion of a dilator over the guidewire to gradually expand the puncture tract and create a pathway for the choledochoscope. (E) Progressive dilation of the tract using sequentially larger dilators to accommodate the rigid choledochoscope. (F) Final dilation achieved. The tract is now sufficiently wide for the introduction of the choledochoscope. (G) Introduction of the rigid choledochoscope through the dilated tract into the bile duct. (H) Postprocedure placement of an external drainage catheter (pigtail catheter) connected to the bile duct and secured to the skin.

Figure 3

Stone under the choledochoscope.