Posted on 2023-09-20 02:04:02 by Sathish

    The first procedure to be done is ERCP in which the bile duct stones will be removed and a biliary stent will be placed. The endoscope used is known as side viewing upper gastrointestinal endoscope (duodenoscope) which sees the area on sideways so that the identification of the ampulla will be easy.

    The procedure is done under general anaesthesia usually Total Intra Venous Analgesia (TIVA) as per anaesthetist choice. After anaesthesia the patient will be in the side position or supine position or even prone position depending as per the endoscopist choice. The side viewing endoscope is passed into the duodenum second part and ampulla is identified. After this a guide wire is passed into the ampulla of Vater. It can go to bile duct or pancreatic duct. 

    The anatomical knowledge of the endoscopist and C arm guidance will help the endoscopist to pass the guide wire into the common bile duct. At this stage next step is to widen the opening of the ampulla of Vater. This widening is done by making an opening over the ampulla with endoscopic needle, knife and or wire sphincterotome.

    After this, an instrument called cannula is passed into the bile duct to inject contrast into the biliary system with imaging, by C arm (Image Intensifier). This imaging will give an information about the stones like site, size and number of stones.

    This is very important to make a note of all those things because to confirm the completion of the stone retrieval at the end of the procedure. Once these details are gathered then the stone extraction is done with balloon or basket.

    Large stones may not come through the ampulla. In that case the ampulla is dilated by a technique called balloon sphincteroplasty in which the ampullary opening is dilated. This helps to retrieve the stones fully and extracted stones are left in the duodenum which comes out through faecal matter.

    But some time there may be technical difficulty in removing the stones because of its size or hardness of the stone. In such situation an instrument called lithotripter will be used to crush the stones. There are various lithotripters are available. The commonly used lithotripters are mechanical lithotripter, LASER lithotripter, hydraulic lithotripter etc.

    The end result of the lithotripter is that it crushes the stone and aids in retrieving the stones through ampulla of Vater. Once all the stones are removed then the complete removal is confirmed with check cholangiogram. In case of aby doubt, occlusion cholangiogram will be done to confirm the stone clearance of common bile duct. After this, a plastic stent is placed in the bile duct across the ampulla of Vater for better healing of the ampulla. Immediately after biliary sphincterotomy, there will be ampullary oedema which may block the free flow of infected bile into the duodenum. This can be prevented by placing a biliary stent across the ampulla of Vater. Also, stent may help to perform safe laparoscopic cholecystectomy in case of any technical difficulties.

    Stent is a plastic tube with various sizes and types to place across the ampulla. The various types of biliary stents are straight stent, single pigtail stent and double pigtail stent. The pig tail mechanism is to prevent the slippage of stent into or outside the bile duct.

    After this ERCP and stone extraction from the bile duct patient is observed for another one or two days to perform next procedure. That means laparoscopic cholecystectomy or open cholecystectomy will be done one or two days after ERCP and stenting procedure.

    There are couple of reasons to wait one or two days to perform laparoscopic cholecystectomy or open cholecystectomy following ERCP. The common reasons are:

  1. Air in the intestines may give technical difficulty during surgery
  2. Stabilize the patient in case of associated sepsis.
  3. Assess the improvement of biliary pancreatitis
  4. Reduce jaundice in case of high serum bilirubin level
  5. To improve the organ dysfunction if any.
  6. To identify and treat post ERCP pancreatitis


  1. Air in the intestines

    Gastrointestinal system starts from cricopharynx (starting point of food pipe) to anal canal with approximate length of nine meters. During fasting, there will not be any contents in the stomach or duodenum. During diagnostic and therapeutic endoscopy, air or carbon dioxide is inflated into the intestinal system to distend the organ for better visualization of the mucosa. In case of any therapeutic endoscopy procedure, continuous and prolonged inflation of gas is required to complete the procedure. This ends up with accumulation of large amount of air in the intestines and so intestines will be distended. This air will go out as flatus and will take about 24 hours to clear all the air. If carbon dioxide is used it will be evacuated much faster than air. So, immediately after any therapeutic endoscopic procedure there will be bowel distension which will give technical difficulty to perform laparoscopic surgery.

2). Stabilize the patient in case of associated sepsis.

    Sometimes patient come to the hospital with severe infection and increased serum bilirubin. ERCP is a procedure which removes the bile duct stone and so reduces the sepsis. In patient with severe systemic infection and deep jaundice, enough time is given to recover from the sepsis and then the gall bladder removal surgery is done.

3). Biliary pancreatitis.

    Patient with bile duct stones may present with biliary pancreatitis. In these patients ERCP is done to remove the bile duct stones. But the pancreatitis will be ongoing process and may end up with complications related to pancreatitis. So, in patient with biliary pancreatitis enough time is given to recover from pancreatitis and so there may be some time delay in performing the gall bladder removal surgery after ERCP.

4). Reduce jaundice

    Most often, the patients present with bile duct stone and jaundice with serum bilirubin level of less than 10mg%. However, if the serum bilirubin level is extremely high, further time is given to reduce it to less than 10 mg%. This could take a few days and then the Gall bladder removal surgery will be proceeded.

 5). To improve another organ dysfunction

    Sometimes patients present with gall stone disease and bile duct stones along with another organ dysfunction. In these patients the order of treatment regimen will be to stabilize the patient first, followed by ERCP with bile duct stone extraction and biliary stenting. After this procedure enough time is given for the recovery of the organ and then the gall bladder removal surgery will be done.

6). Time to recover from post ERCP pancreatitis.

    About 10% of patients undergoing ERCP will develop ERCP induced pancreatitis. This is commonly due to repeated cannulation of pancreatic duct during the procedure or impaction of stone at the Ampulla of Vater. So, after 24 hours of ERCP and Common bile duct stone extraction, if the patient complaints of severe epigastric pain, then ERCP induced pancreatitis has to be considered. These patients may have increasing abdominal pain and elevated levels of serum amylase and serum lipase. These patients require pancreatitis treatment, depending on the severity of their condition. Once pancreatitis resolves then only the gall bladder removal surgery will be done. The gall bladder removal procedure will be performed after the pancreatitis has subsided.

    Once the gall bladder treatment is over then the stent placed in the common bile duct will be removed. This stent will be there for about six weeks and at the end of sixth week, a check MRCP is done to rule out any residual stones in the bile duct. If there are no stones then the stent will be removed. 

    After successful ERCP and stone extraction with biliary stenting, laparoscopic cholecystectomy will be performed. Here, there is a possibility of technical difficulty due to chronic infection of biliary tree. Placement of biliary stent at the time of ERCP will be of very useful during laparoscopic cholecystectomy because the presence of stent in the bile duct can be felt laparoscopically which helps to dissect the Calot’ triangle and so can avoid bile duct injuries.

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