Case 3.7 – Choledocolethiasis & Cholecystectomy [SDL]

Clinical Presentation Differences

Feature	Choledocholithiasis	Malignant Obstruction
Onset	Acute, intermittent episodes	Gradual, progressive
Pain	Severe, colicky RUQ pain; often postprandial	Dull, persistent epigastric pain or painless
Jaundice	Fluctuating; may wax and wane	Progressive, deepening; Courvoisier's sign (painless, palpable gallbladder)
Fever	Common if cholangitis develops	Rare unless infected
Weight Loss	Unusual	Common, progressive
Prior History	History of biliary colic, gallstones	Risk factors: age >60, smoking, chronic pancreatitis

Evaluation Differences

Laboratory Findings:

• Choledocholithiasis:
  • Elevated conjugated bilirubin (typically 2-15 mg/dL)
  • Elevated alkaline phosphatase and GGT (cholestatic pattern)
  • ALT/AST may be markedly elevated initially (\>1000 U/L), then decrease
  • If cholangitis: elevated WBC, positive blood cultures
  • Tumor markers (CA 19-9, CEA) usually normal
• Malignant Obstruction:
  • Progressive elevation of bilirubin (often >15 mg/dL)
  • Persistent cholestatic enzyme elevation
  • Transaminases typically mildly elevated
  • Elevated tumor markers (CA 19-9 >100 U/mL suggestive of pancreatic/biliary malignancy)
  • Anemia may be present

Imaging Studies:

• Ultrasound:
  • Choledocholithiasis: Stones visible in gallbladder ± CBD (sensitivity 50-70% for CBD stones), dilated CBD (\>6 mm)
  • Malignancy: Mass lesion, "double duct sign" (dilated CBD + pancreatic duct), no stones visible
• CT Abdomen/Pelvis with contrast:
  • Choledocholithiasis: Stones may appear as filling defects, no mass
  • Malignancy: Mass in pancreatic head, ampulla, or bile duct; vascular involvement; lymphadenopathy; metastases
• MRCP (Magnetic Resonance Cholangiopancreatography):
  • Excellent for visualizing bile duct anatomy and stones (sensitivity >90% for CBD stones)
  • Can distinguish stones from tumors; shows level and cause of obstruction
• ERCP (Endoscopic Retrograde Cholangiopancreatography):
  • Both diagnostic and therapeutic
  • Allows for stone extraction, biopsy, stent placement

Courvoisier's Sign

A palpable, non-tender gallbladder in the presence of jaundice suggests malignant obstruction rather than choledocholithiasis. Rationale: chronic stone disease typically causes gallbladder fibrosis and scarring, preventing distention; malignant obstruction occurs in a previously normal gallbladder that can distend.

Acute Cholecystitis

Pathophysiology: Inflammation of the gallbladder, typically due to cystic duct obstruction by a gallstone, leading to chemical inflammation and secondary bacterial infection.

Clinical Presentation:

• Severe, constant RUQ or epigastric pain (\>6 hours)
• Fever (usually low-grade, <38.5°C)
• Nausea and vomiting
• Murphy's sign: inspiratory arrest during deep palpation of RUQ
• Usually NO jaundice (unless Mirizzi syndrome or concomitant choledocholithiasis)
• Leukocytosis (WBC 12,000-15,000)

Evaluation:

• Lab: CBC (leukocytosis), CMP (usually normal bilirubin and liver enzymes unless complicated), lipase (to rule out pancreatitis)
• Imaging: Right upper quadrant ultrasound (first-line)
  • Gallstones
  • Gallbladder wall thickening (\>4 mm)
  • Pericholecystic fluid
  • Sonographic Murphy's sign
• HIDA scan: If ultrasound equivocal; non-filling of gallbladder indicates cystic duct obstruction

Management:

• NPO, IV fluids, IV antibiotics (broad-spectrum covering gram-negatives and anaerobes: ceftriaxone + metronidazole, or piperacillin-tazobactam)
• Pain control (NSAIDs, opioids)
• Definitive treatment: Cholecystectomy
  • Early cholecystectomy (within 72 hours of symptom onset) preferred - lower complications, shorter hospital stay
  • Laparoscopic approach preferred (see Question 5)
• If patient unfit for surgery: Percutaneous cholecystostomy for gallbladder drainage

Acute Cholangitis

Pathophysiology: Infection of the biliary tree secondary to obstruction (most commonly from CBD stone, but also stricture, malignancy, or stent occlusion). Bacteria ascend from duodenum into obstructed biliary system.

Clinical Presentation - Charcot's Triad:

1. Fever with rigors (95% of cases)
2. RUQ pain (70% of cases)
3. Jaundice (60% of cases)

Note: Only 50-70% of patients present with all three findings

Reynolds' Pentad (severe/suppurative cholangitis):

• Charcot's triad PLUS:
• Altered mental status
• Hypotension/septic shock

Evaluation:

• Lab:
  • Leukocytosis (WBC >10,000, often >15,000)
  • Elevated conjugated bilirubin
  • Elevated alkaline phosphatase and GGT
  • Blood cultures (positive in 50%, commonly E. coli, Klebsiella, Enterococcus)
• Imaging:
  • Ultrasound: Dilated CBD (\>6 mm), stones, intrahepatic duct dilatation
  • CT: May show biliary dilatation and identify level of obstruction
  • MRCP: Detailed biliary anatomy if ERCP not immediately available

Management - Medical Emergency:

• Immediate resuscitation:
  • IV fluids (aggressive for sepsis)
  • Broad-spectrum IV antibiotics (must cover gram-negatives and anaerobes): piperacillin-tazobactam or carbapenem (meropenem)
  • Hemodynamic support if septic shock
• Urgent biliary decompression (within 24 hours):
  • ERCP with sphincterotomy and stone extraction (first-line, success rate 85-95%)
    • Endoscopic sphincterotomy: Incision of sphincter of Oddi to facilitate stone removal
    • Stone extraction using balloon catheter or basket
    • If stones cannot be removed: Biliary stent placement for drainage
  • If ERCP fails or unavailable: Percutaneous transhepatic biliary drainage (PTBD)
• Interval cholecystectomy: After recovery from acute episode (2-6 weeks) to prevent recurrence

Key Differences Summary

Feature	Acute Cholecystitis	Acute Cholangitis
Site	Gallbladder	Bile ducts
Obstruction	Cystic duct	Common bile duct
Jaundice	Rare	Common
Severity	Usually localized	Systemic infection, sepsis risk
Treatment	Cholecystectomy	Urgent ERCP + decompression

Pathophysiology

Acute gallstone pancreatitis occurs when a gallstone migrates through the cystic duct and transiently obstructs the ampulla of Vater, causing reflux of bile into the pancreatic duct and activation of pancreatic enzymes. It accounts for 40-70% of acute pancreatitis cases.

Clinical Presentation

• Severe epigastric pain radiating to the back
• Nausea and vomiting
• Abdominal tenderness, guarding
• May have concurrent jaundice if stone remains impacted

Diagnosis

• Lab:
  • Elevated lipase and/or amylase (\>3× upper limit of normal)
  • Elevated ALT >150 U/L suggests gallstone etiology (PPV 95%)
  • May have hyperbilirubinemia, elevated alkaline phosphatase
  • CBC, CMP to assess for complications (leukocytosis, hypocalcemia, elevated BUN/Cr)
• Imaging:
  • RUQ ultrasound: Identify gallstones, CBD dilatation
  • CT abdomen with contrast (if diagnosis uncertain or severe): Pancreatic inflammation, necrosis, fluid collections
• Severity assessment:
  • Ranson's criteria or APACHE II score
  • SIRS criteria (systemic inflammatory response syndrome)

Management

Initial Supportive Care:

• Aggressive IV fluid resuscitation: Lactated Ringer's solution 250-500 mL/hr initially; goal urine output >0.5 mL/kg/hr
• NPO initially - advance diet as tolerated when pain improves (early enteral nutrition within 48-72 hours reduces complications in severe pancreatitis)
• Pain control: Opioids as needed (morphine, hydromorphone)
• Anti-emetics: Ondansetron, promethazine
• Electrolyte monitoring and repletion (especially calcium, magnesium)
• Antibiotics: NOT routinely indicated unless evidence of infected necrosis or concurrent cholangitis

Assess for Concurrent Choledocholithiasis/Cholangitis:

• If patient has persistent jaundice, dilated CBD on imaging, or signs of cholangitis → Urgent ERCP (within 24 hours)
• ERCP indications in gallstone pancreatitis:
  • Concurrent acute cholangitis (Charcot's triad)
  • Evidence of persistent CBD obstruction (bilirubin >4 mg/dL, dilated CBD)
  • Severe pancreatitis with suspected impacted stone
• ERCP procedure:
  • Endoscopic sphincterotomy to relieve obstruction
  • Stone extraction with balloon or basket
  • Biliary stent placement if stones cannot be cleared or edema present
• If no evidence of cholangitis or persistent obstruction → No urgent ERCP needed; MRCP or endoscopic ultrasound (EUS) can be performed electively to evaluate CBD

Definitive Management - Cholecystectomy:

• Mild pancreatitis: Cholecystectomy during same admission once patient recovers (typically within 48-72 hours, when pain resolves and patient tolerates diet)
• Severe pancreatitis with necrosis: Delay cholecystectomy until inflammation resolves (6-8 weeks) to reduce surgical risk
• Rationale: Early cholecystectomy (same admission) reduces recurrent pancreatitis from 30% to \<5%; delayed cholecystectomy increases risk of recurrent gallstone-related complications
• If patient unfit for surgery: ERCP with sphincterotomy alone reduces (but does not eliminate) recurrent pancreatitis risk

Management of Severe Pancreatitis Complications:

• Pancreatic necrosis: Conservative management; consider antibiotics if infected (CT-guided FNA for culture)
• Pseudocyst: Observation if asymptomatic; drainage if symptomatic, infected, or enlarging
• Organ failure: ICU support with ventilation, vasopressors, renal replacement therapy as needed

Summary Algorithm

1. Diagnosis of gallstone pancreatitis → Supportive care + IV fluids
2. Assess for cholangitis or persistent CBD obstruction
   • If present → Urgent ERCP within 24 hours
   • If absent → Conservative management
3. Mild pancreatitis → Same-admission cholecystectomy after recovery
4. Severe pancreatitis → Delayed cholecystectomy after 6-8 weeks

Treatment of Gallbladder Stones (Cholelithiasis)

1. Cholecystectomy (Definitive Treatment)

• Laparoscopic cholecystectomy: Gold standard (see Question 5 for details)
• Open cholecystectomy: For complicated cases, conversion from laparoscopic
• Indications:
  • Symptomatic gallstones (biliary colic, acute cholecystitis)
  • Complications (pancreatitis, cholangitis, gallbladder perforation)
  • Gallbladder polyps >10 mm or porcelain gallbladder (malignancy risk)

2. Percutaneous Cholecystostomy

• Temporary drainage for acute cholecystitis in critically ill or high-risk surgical patients
• Allows for interval cholecystectomy after patient stabilizes

3. Medical Dissolution Therapy (Rarely Used)

• Ursodeoxycholic acid (UDCA): For small (\<10 mm), cholesterol stones in functioning gallbladder
• Requires 6-24 months; success rate 30-50%; high recurrence rate (50% at 5 years)
• Limited role; only for patients who refuse or cannot undergo surgery

Treatment of Common Bile Duct Stones (Choledocholithiasis)

1. ERCP with Sphincterotomy and Stone Extraction (First-Line)

• Procedure:
  • Endoscope advanced to duodenum
  • Cannulation of ampulla of Vater
  • Endoscopic sphincterotomy: Electrocautery incision of sphincter of Oddi to widen opening
  • Stone extraction: Balloon catheter or Dormia basket to sweep stones into duodenum
  • Fluoroscopy used for visualization
• Success rate: 85-95% for stone clearance
• Indications:
  • Confirmed or suspected choledocholithiasis
  • Acute cholangitis (urgent)
  • Gallstone pancreatitis with persistent obstruction
• Complications: Pancreatitis (5%), bleeding (2%), perforation (0.5%), cholangitis

2. Biliary Stent Placement

• Indications:
  • Stones too large to extract (\>15 mm)
  • Impacted stones
  • Severe inflammation preventing safe stone extraction
  • Temporary measure to relieve obstruction
• Types:
  • Plastic stents (temporary, replaced every 3-6 months)
  • Metal stents (for malignant obstruction or long-term palliation)
• Mechanism: Stent bypasses obstruction, allows bile drainage into duodenum
• May allow interval stone extraction or lithotripsy after inflammation subsides

3. Mechanical Lithotripsy

• For large or impacted stones during ERCP
• Mechanical basket crushes stone into smaller fragments for extraction

4. Extracorporeal Shock Wave Lithotripsy (ESWL)

• External shock waves fragment large stones
• Followed by ERCP for stone extraction
• Rarely used; mainly for large (\>15 mm) CBD stones when other methods fail

5. Surgical CBD Exploration

• Laparoscopic CBD exploration: During cholecystectomy, stones extracted via cystic duct or choledochotomy
• Open CBD exploration: Formal choledochotomy, stone extraction, T-tube placement
• Indications:
  • CBD stones discovered intraoperatively during cholecystectomy
  • Failed ERCP
  • Altered anatomy precluding ERCP (e.g., Roux-en-Y gastric bypass)
• Approach: Can be performed at time of cholecystectomy or as separate procedure

6. Percutaneous Transhepatic Cholangiography (PTC) with Drainage

• For patients in whom ERCP fails or is not feasible
• Percutaneous access through liver into bile ducts
• Allows for stone extraction, balloon dilation, or stent placement

Management Strategy for Choledocholithiasis + Cholelithiasis

Approach 1 (Most Common):

1. Pre-operative ERCP for CBD stone clearance
2. Followed by laparoscopic cholecystectomy (same admission or within 2-6 weeks)

Approach 2 (Single-Stage):

• Laparoscopic cholecystectomy with laparoscopic CBD exploration
• Requires advanced laparoscopic skills

Approach 3 (ERCP Only):

• For patients unfit for surgery
• ERCP with sphincterotomy + stone extraction
• Reduces but does not eliminate risk of recurrent biliary complications

Choice of Treatment

• Asymptomatic gallbladder stones: Observation (no treatment)
• Symptomatic gallbladder stones: Cholecystectomy
• CBD stones with cholangitis: Urgent ERCP
• CBD stones without cholangitis: ERCP + interval cholecystectomy
• CBD stones found during surgery: Laparoscopic/open CBD exploration or post-op ERCP

Indications for Cholecystectomy

Absolute Indications:

• Acute cholecystitis - early cholecystectomy (within 72 hours) preferred
• Gallstone complications:
  • Gallstone pancreatitis (after recovery from acute episode)
  • Cholangitis (after biliary decompression)
  • Gallbladder perforation
  • Cholecystoenteric fistula
  • Gallstone ileus
• Symptomatic cholelithiasis - recurrent biliary colic (\>1 episode)
• Acalculous cholecystitis (critically ill patients)
• Gallbladder dyskinesia with symptoms and low ejection fraction (\<35%) on HIDA scan
• Porcelain gallbladder - calcified gallbladder wall (15-25% malignancy risk)
• Gallbladder polyps:
  • >10 mm (malignancy risk)
  • Polyps with symptoms
  • Growing polyps on serial imaging
• Gallbladder carcinoma

Relative Indications:

• Diabetes mellitus with gallstones (higher risk of complications)
• Hemolytic disorders (sickle cell, hereditary spherocytosis) with gallstones - increased pigmented stone formation
• Bariatric surgery patients - concurrent cholecystectomy considered if gallstones present

NOT Indicated:

• Asymptomatic gallstones (incidental finding) - only 10-20% become symptomatic over 10-20 years

Laparoscopic Cholecystectomy

Technique:

• Four small incisions (5-10 mm)
• Pneumoperitoneum created with CO2 insufflation
• Laparoscope and instruments inserted
• Critical view of safety: Identify cystic duct, cystic artery, hepatocystic triangle before clipping
• Cystic duct and artery clipped and divided
• Gallbladder dissected from liver bed
• Intraoperative cholangiogram (optional) to evaluate CBD

Advantages:

• Reduced post-operative pain - smaller incisions
• Shorter hospital stay - often same-day or 23-hour discharge vs. 3-5 days for open
• Faster recovery and return to work - 1-2 weeks vs. 4-6 weeks
• Better cosmetic result - minimal scarring
• Lower wound infection rate - smaller incisions
• Reduced post-operative ileus
• Lower incidence of incisional hernias

Disadvantages:

• Requires specialized equipment and training
• Longer operative time (initially)
• Pneumoperitoneum may cause shoulder pain (referred from diaphragm)
• May require conversion to open (5-10% of cases)

Contraindications (may require open approach):

• Inability to tolerate pneumoperitoneum (severe cardiopulmonary disease)
• Diffuse peritonitis
• Suspected gallbladder cancer
• Severe coagulopathy

Open Cholecystectomy

Technique:

• Right subcostal (Kocher) incision or midline incision
• Direct visualization of gallbladder, cystic duct, and cystic artery
• Dissection and removal of gallbladder

Advantages:

• Better visualization in complex cases
• Easier control of bleeding
• Better access for CBD exploration
• No need for specialized equipment

Disadvantages:

• Larger incision - more post-operative pain
• Longer hospital stay (3-5 days)
• Prolonged recovery (4-6 weeks)
• Higher wound complication rate (infection, dehiscence, hernia)
• Poor cosmetic result

Indications for Primary Open Approach:

• Suspected gallbladder cancer
• Prior extensive upper abdominal surgery with adhesions
• Portal hypertension with varices
• Cholecystoenteric fistula
• Inability to achieve safe laparoscopic access

Conversion from Laparoscopic to Open (5-10%):

• Severe inflammation obscuring anatomy
• Inability to achieve critical view of safety
• Uncontrolled bleeding
• CBD injury identified intraoperatively
• Suspicion of malignancy

Comparison Table

Feature	Laparoscopic	Open
Incision size	4 small (5-10 mm)	1 large (10-15 cm)
Hospital stay	Same-day to 1 day	3-5 days
Recovery time	1-2 weeks	4-6 weeks
Pain	Minimal	Significant
Complications	Lower overall	Higher wound complications
Conversion rate	5-10%	N/A
Operative time	60-90 minutes	45-75 minutes

Current Standard

Laparoscopic cholecystectomy is the gold standard for gallbladder removal in >90% of cases due to superior patient outcomes, faster recovery, and lower morbidity. Open cholecystectomy is reserved for specific complicated cases or when laparoscopic approach is not feasible or safe.

Overall Complication Rates

• Laparoscopic cholecystectomy: 5-7% overall complication rate
• Open cholecystectomy: 10-15% overall complication rate
• Mortality: <0.5% for both approaches (higher in emergency surgery and elderly)

Intraoperative Complications

1. Bile Duct Injury (Most Serious)

• Laparoscopic: 0.4-0.6% (higher than open)
• Open: 0.2-0.3%
• Mechanism:
  • Laparoscopic: Misidentification of CBD as cystic duct (two-dimensional view), excessive traction, thermal injury
  • Open: Typically from direct dissection or cautery
• Types:
  • Transection of CBD or hepatic duct
  • Partial injury or laceration
  • Clipping or ligation of duct
  • Thermal injury from cautery
• Prevention: Critical view of safety before clipping any structures (identify 2 and only 2 structures entering gallbladder: cystic duct and artery)
• Management:
  • Recognition intraoperatively → immediate repair or conversion to open with hepatobiliary surgeon
  • Post-operative recognition → ERCP with stenting or surgical reconstruction (hepaticojejunostomy)
• Consequences: Bile leak, biliary stricture, cholangitis, secondary biliary cirrhosis if untreated

2. Bleeding

• Laparoscopic: 0.5-1%
• Open: 1-2%
• Sources:
  • Cystic artery
  • Hepatic artery injury
  • Liver bed (during dissection)
  • Trocar site vessels (laparoscopic)
• Management: Usually controlled with electrocautery or clips; rarely requires conversion or transfusion

3. Bowel Injury

• Laparoscopic: 0.1-0.3%
• Open: <0.1%
• Mechanism (laparoscopic): Trocar insertion injury, especially in patients with prior abdominal surgery/adhesions
• Management: Primary repair; may require conversion to open

Post-operative Complications

1. Bile Leak

• Laparoscopic: 0.5-1%
• Open: 0.3-0.5%
• Sources:
  • Cystic duct stump (most common)
  • Accessory bile duct from liver bed (duct of Luschka)
  • Unrecognized CBD injury
• Presentation: Abdominal pain, fever, bile drainage from drain (if placed), bile ascites
• Diagnosis: HIDA scan, ERCP, MRCP
• Management:
  • Small leaks: ERCP with sphincterotomy ± biliary stent (reduces pressure, allows healing)
  • Persistent leaks: Percutaneous drainage ± repeat ERCP
  • Large leaks or CBD injury: Surgical repair

2. Retained CBD Stone

• 1-5% if intraoperative cholangiogram not performed
• May present with jaundice, cholangitis, pancreatitis post-operatively
• Management: ERCP with stone extraction

3. Wound Complications

• Infection:
  • Laparoscopic: 1-2% (trocar sites)
  • Open: 5-10% (large incision)
• Incisional hernia:
  • Laparoscopic: \<1% (trocar site hernias rare)
  • Open: 5-15% (especially in obese, diabetic, or immunosuppressed patients)
• Dehiscence:
  • Laparoscopic: Very rare
  • Open: 1-2%

4. Pain

• Laparoscopic:
  • Minimal incisional pain
  • Shoulder pain common (referred from diaphragmatic irritation by CO2), typically resolves in 24-48 hours
• Open:
  • Significant incisional pain (requires more opioid analgesia)
  • Longer duration

5. Intra-abdominal Abscess/Collection

• 1-2% for both approaches
• More common in acute cholecystitis with perforation
• Management: CT-guided percutaneous drainage + antibiotics

6. Post-Cholecystectomy Syndrome

• 10-15% of patients (both approaches)
• Persistent or recurrent symptoms after cholecystectomy: dyspepsia, RUQ pain, diarrhea
• Causes:
  • Retained CBD stone
  • Biliary stricture
  • Sphincter of Oddi dysfunction
  • Cystic duct remnant
  • Non-biliary causes (e.g., peptic ulcer, IBS, pancreatitis)

Specific to Laparoscopic Approach

• Port site hernias: \<1%, more common at umbilical port (10-12 mm)
• Subcutaneous emphysema: Rare, from CO2 dissection into tissues
• Pneumothorax/pneumomediastinum: Very rare
• Gas embolism: Extremely rare but potentially fatal

Specific to Open Approach

• Pulmonary complications: Higher rate (atelectasis, pneumonia) due to splinting from pain
• Deep vein thrombosis/PE: Slightly higher due to longer immobility

Comparison Table

Complication	Laparoscopic	Open
Bile duct injury	0.4-0.6% (higher)	0.2-0.3%
Bile leak	0.5-1%	0.3-0.5%
Bleeding	0.5-1%	1-2%
Wound infection	1-2%	5-10% (higher)
Incisional hernia	\<1%	5-15% (higher)
Bowel injury	0.1-0.3%	<0.1%
Overall morbidity	5-7%	10-15% (higher)

Risk Factors for Complications (Both Approaches)

• Emergency surgery (acute cholecystitis)
• Male gender
• Age >60 years
• Obesity
• Diabetes mellitus
• Cirrhosis/portal hypertension
• Prior upper abdominal surgery
• Acute inflammation obscuring anatomy

Summary

Laparoscopic cholecystectomy has a lower overall complication rate, particularly for wound-related complications (infection, hernia). However, it has a slightly higher rate of bile duct injury due to the technical challenge of two-dimensional visualization. Adherence to the "critical view of safety" technique has reduced this risk. Open cholecystectomy has higher wound morbidity and longer recovery but may be safer in very complex cases where anatomy is severely distorted.

Post-Operative Management After Laparoscopic Cholecystectomy

Immediate Post-Operative Care (PACU/Recovery):

• Monitoring: Vital signs, pain, nausea, urine output
• Pain management:
  • Multimodal analgesia: NSAIDs (ketorolac) + acetaminophen
  • Opioids as needed for breakthrough pain
  • Shoulder pain (from CO2): ambulation, NSAIDs, heating pad
• Anti-emetics: Ondansetron for post-operative nausea
• Diet: Clear liquids once awake; advance to regular diet as tolerated (usually same day)
• Ambulation: Early mobilization (within 2-4 hours) to reduce shoulder pain and prevent DVT

Hospital Course:

• Duration:
  • Uncomplicated laparoscopic cholecystectomy: Same-day discharge or 23-hour observation
  • Acute cholecystitis: 1-2 days
  • Open cholecystectomy: 3-5 days
• Monitoring:
  • Vital signs q4-6 hours
  • Watch for fever (\>38.5°C), tachycardia (infection, bleeding)
  • Assess for abdominal distention, tenderness
  • Monitor drain output if placed (character, volume)
• Labs: Not routinely needed unless complications suspected

Discharge Criteria:

• Tolerating oral intake
• Pain controlled on oral medications
• Ambulating independently
• No signs of complications (fever, bleeding, bile leak)
• Able to void

Discharge Instructions:

• Activity:
  • Resume normal activities as tolerated
  • No heavy lifting (\>10-15 lbs) for 1-2 weeks
  • Driving: when off opioids and comfortable (usually 3-5 days)
  • Return to work: 1-2 weeks for laparoscopic, 4-6 weeks for open
• Diet: Regular diet; no specific restrictions. May have temporary diarrhea (10-15%) due to continuous bile flow into intestine
• Wound care:
  • Keep incisions clean and dry for 48 hours
  • Shower after 48 hours; no bathing/swimming for 1 week
  • Steri-strips fall off on their own
• Medications:
  • Pain: NSAIDs/acetaminophen first-line; opioids for severe pain (limited supply)
  • Stool softener if taking opioids

Warning Signs to Report:

• Fever >38.5°C (101.5°F)
• Severe or worsening abdominal pain
• Nausea/vomiting preventing oral intake
• Jaundice (yellowing of skin/eyes)
• Wound redness, drainage, or opening
• Inability to urinate

Follow-Up:

• Office visit in 2-4 weeks (sooner if complications)
• Pathology review (routine gallbladder histology to exclude incidental malignancy)

Post-Operative Management After CBD Exploration

Additional Considerations:

• Duration of stay: Typically 2-5 days (longer than simple cholecystectomy)
• T-tube management (if placed during open CBD exploration):
  • T-tube is a catheter placed in CBD after choledochotomy, exits through abdominal wall
  • Allows external bile drainage and ensures CBD patency
  • Post-operative care:
    • Keep T-tube to gravity drainage
    • Monitor output: typically 200-500 mL/day initially, decreases over time
    • Record output daily
    • Watch for excessive output (\>1 L/day suggests distal obstruction)
  • T-tube cholangiogram:
    • Performed 7-10 days post-operatively
    • Contrast injected through T-tube to visualize biliary tree
    • Ensures no retained stones, no leak, free flow into duodenum
  • T-tube removal:
    • If cholangiogram normal: clamp T-tube for 24-48 hours
    • If patient tolerates clamping (no pain, fever, nausea): remove T-tube (10-14 days post-op)
    • Outpatient removal (simple bedside procedure)
    • Tract closes spontaneously within 48 hours
• Surgical drain (if placed):
  • Jackson-Pratt (JP) drain near liver bed or CBD repair site
  • Monitor output: should be serosanguinous, decreasing volume
  • Watch for bile (green fluid) suggesting bile leak
  • Remove when output <30 mL/day and non-bilious (typically 2-5 days)

Monitoring for Complications:

• Bile leak:
  • Signs: fever, abdominal pain, increased drain output (bile), jaundice
  • Diagnosis: HIDA scan, ERCP, drain fluid bilirubin level
  • Management: ERCP with sphincterotomy + stent, percutaneous drainage
• Retained stone:
  • Post-operative jaundice, cholangitis, pancreatitis
  • Diagnosis: LFTs, ultrasound, MRCP
  • Management: ERCP with stone extraction
• Stricture:
  • Late complication (weeks to months)
  • Progressive jaundice, cholangitis
  • Diagnosis: MRCP, ERCP
  • Management: Endoscopic dilation ± stent, or surgical reconstruction

Post-ERCP with Sphincterotomy/Stent Placement

Immediate Post-Procedure Care:

• Monitoring:
  • Vital signs q15-30 minutes initially
  • Watch for post-ERCP pancreatitis (most common complication, 5%)
  • Assess for bleeding (hematemesis, melena, hemodynamic instability)
  • Monitor for perforation (severe abdominal pain, peritoneal signs)
• NPO: Initially 4-6 hours, then advance diet if no abdominal pain
• Labs: Amylase/lipase at 4-6 hours post-procedure to screen for pancreatitis
• Observation: 4-8 hours for uncomplicated ERCP; admit if complications suspected

Post-ERCP Pancreatitis:

• Occurs in ~5% of cases
• Symptoms: abdominal pain, nausea, vomiting
• Management: Supportive care (IV fluids, NPO, pain control) as for gallstone pancreatitis
• Usually mild and self-limited

Stent Management:

• Plastic biliary stents:
  • Placed for temporary drainage (impacted stone, edema, stricture)
  • Must be removed or exchanged in 3-6 months to prevent occlusion and cholangitis
  • Follow-up ERCP scheduled for stent removal after inflammation resolves
• Pancreatic duct stents:
  • Prophylactic placement to reduce post-ERCP pancreatitis risk
  • Typically self-migrates within 1-2 weeks

Long-Term Considerations

Dietary Changes:

• Most patients tolerate regular diet without issues
• ~10-15% experience post-cholecystectomy diarrhea (bile salt-induced); may improve with cholestyramine
• No evidence that low-fat diet is necessary after cholecystectomy

Post-Sphincterotomy:

• Sphincter of Oddi permanently opened
• Small increased risk of ascending cholangitis, but overall low
• No specific long-term precautions needed

Summary of Post-Operative Management Principles

1. Pain control: Multimodal analgesia, minimize opioids
2. Early mobilization and feeding: Reduces complications, shortens hospital stay
3. Monitor for complications: Bile leak, bleeding, infection, retained stones
4. Drain/T-tube management: Monitor output, remove when safe
5. Patient education: Warning signs, activity restrictions, follow-up
6. Follow-up imaging: T-tube cholangiogram if CBD exploration performed
7. Stent removal: Ensure plastic stents removed within 3-6 months