ERCP

PROCEDURE PERFORMED:                  ERCP.

PROCEDURE INDICATION:                    Common bile duct stones on intraoperative cholangiography post cholecystectomy.

POSTPROCEDURE DIAGNOSES:

1.  Multiple common bile duct stones removed after sphincterotomy with balloon stone extraction of the eXit cholangiography revealing the bile duct free of any residual stones.

2.  Intact intrahepatic ducts and intact cystic duct remnant.

MEDICATIONS:                                           Per anesthesia with intubation.

PROCEDURE IN DETAIL:                        The risks of perforation, bleeding, infection, sedation, and anesthesia were outlined.  Assistance of an interpreter was utilized.  With the patient intubated in the prone position, the scope was advanced to the second portion of the duodenum after suctioning the stomach clear of fluid.  The major ampulla was identified and noticed to be bulging.  Cannulation initially secured the ampulla and wire guidance went into the pancreatic directions on two occasions.  There was a sensation that there is something impacting the distal bile duct.  With angulation change and wire guidance, common bile duct was cannulated and cholangiography revealed multiple filling defects within the bile duct.  Sphincterotomy then undertaken with a controlled fashion Erbe generator.  The wires then advanced into proximal biliary tree, the catheter removed, and 9 to 12 mm balloon was utilized to occlude the bile duct distally and removed stones and then moved more proximally and removed more stones, then high up into the right hepatic duct and gradually brought back into the common hepatic duct thereby trapping the residual stones and pulling them out under eXit cholangiography guidance.  Multiple stones were seen within the duodenum at the completion of the procedure.  These appeared to be cholesterol stones.  There is no bleeding from the sphincterotomy site.  The patient will be managed postoperative anesthesia in the immediate postoperative setting.  She will be continued on antibiotic fluids, analgesics, antiemetics, as previously outlined.  The diet will be advanced based upon progress over the next few hours.  Lab work to be ordered for the morning.