Treatment-Associated Disorders

Case 1 Postcholecystectomy ObstructionA 74-year-old man presented with generalized itching and mild jaundice. A year earlier, he had undergone a laparoscopic cholecystectomy. Laboratory test results included total bilirubin, 4.2 mg/dL; direct bilirubin, 3.6 mg/dL; alkaline phosphatase, 503 IU/L; aspartate aminotransferase, 841 IU/L; and alanine aminotransferase, 561 IU/L. Serum immunoelectrophoresis showed diffuse hyperglobulinemia; the IgG level was 2220 mg/dL. The level of tumor marker CA19-9 was elevated to 550 U/L as a result of chronic cholangitis. Findings of a CT scan of the abdomen were normal. Endoscopic retrograde cholangiopancreatography showed a surgical clip obstructing the common biliary tract. Residual stones are the leading cause of biliary obstruction; they occur in up to 2% of post–laparoscopic cholecystectomy patients. The clip was surgically removed; the patient’s clinical and laboratory findings gradually improved after the operation. There has been no recurrence of biliary obstruction 1 year after clip removal. Minimally invasive laparoscopic cholecystectomy generally is associated with a shorter hospital stay, fewer complications, less trauma, and a lower incidence of cardiac and respiratory complications than open cholecystectomy.^1-5 It is therefore often the procedure of choice for patients who are at high operative risk, such as elderly persons and those with cardiac and respiratory disease.^2,6 Jaundice occurs rarely after the laparoscopic procedure.⁷However, an increased incidence of common bile duct or hepatic duct injury exists with laparoscopic cholecystectomy.^2,4 Furthermore, these bile duct injuries tend to be higher in the duct system and more extensive than those that occur in traditional cholecystectomy; thus, the likelihood of successful reconstruction is reduced.⁸