A 53-year-old male presented to Dr. Raman Garg with progressive jaundice, upper abdominal pain and dark-coloured urine. Investigations confirmed obstructive jaundice. MRCP revealed a large 18 mm stone impacted in the intrapancreatic portion of the common bile duct (CBD), causing complete biliary obstruction.
The patient had already undergone two ERCP attempts, but both procedures failed because the stone was firmly impacted and could not be extracted endoscopically.
Definitive Surgical Management
As endoscopic treatment had failed, surgery was advised. The patient underwent open cholecystectomy with common bile duct exploration. The impacted stone was carefully removed from the distal CBD.
To ensure complete duct clearance, intraoperative choledochoscopy was performed, allowing direct visualization of the entire biliary tree. No residual stones were found, confirming complete clearance before closure.
Postoperative Recovery
- Jaundice gradually resolved
- Oral diet was resumed early
- No postoperative complications
- Discharged on the second postoperative day in satisfactory condition
Why This Case Is Special
Most common bile duct stones can be removed by ERCP, which is the standard treatment. However, large impacted stones in the intrapancreatic CBD may occasionally resist endoscopic extraction despite multiple attempts.
In such situations, CBD exploration with intraoperative choledochoscopy provides direct visualization and complete stone clearance, helping prevent retained stones and recurrent biliary obstruction. This case highlights the role of advanced hepatobiliary surgery when endoscopic treatment is unsuccessful.
Case Summary
| Consultant Surgeon | Dr. Raman Garg |
|---|---|
| Hospital | Bombay Gastro & Cancer Institute, Bathinda |
| Patient | 53-year-old Male |
| Diagnosis | Obstructive jaundice due to an 18 mm impacted distal CBD stone |
| Procedures | Open cholecystectomy, CBD exploration and intraoperative choledochoscopy |
| Outcome | Complete duct clearance, uneventful recovery and discharge on Day 2 |
Frequently Asked Questions
What is a CBD stone?
A common bile duct stone is a gallstone that moves from the gallbladder into the main bile duct. It can block bile flow and cause jaundice, pain, cholangitis or pancreatitis.
What symptoms can an impacted CBD stone cause?
Symptoms may include yellowing of the eyes or skin, upper abdominal pain, dark urine, pale stools, fever with chills, nausea and vomiting.
What is obstructive jaundice?
It occurs when a blocked bile duct prevents bile from reaching the intestine, causing bilirubin to build up in the blood.
What is ERCP?
ERCP is an endoscopic procedure used to remove bile duct stones without surgery and is the first-line treatment for most CBD stones.
Why can ERCP fail?
ERCP may fail when a stone is very large, tightly impacted, deep in the intrapancreatic CBD, associated with duct narrowing or affected by swelling from previous attempts.
What happens if ERCP fails?
Surgery is often the safest definitive treatment. Surgical CBD exploration allows complete stone removal under direct vision.
What is CBD exploration surgery?
The surgeon opens the common bile duct, removes the stone and confirms that the duct is clear before closure.
What is intraoperative choledochoscopy?
A small camera is passed into the bile duct during surgery to inspect the biliary tree and ensure no stones remain.
Why was choledochoscopy used in this case?
Because two ERCP attempts had failed, choledochoscopy confirmed complete clearance and reduced the risk of retained stones or future obstruction.
Was the gallbladder also removed?
Yes. Open cholecystectomy was performed to reduce the risk of future gallstones and recurrent bile duct stones.
How long is recovery after CBD exploration?
Most patients begin eating within a day or two, start walking early and can be discharged within a few days if recovery is uneventful.
Can CBD stones return after surgery?
Recurrence is uncommon after complete duct clearance and gallbladder removal, although follow-up remains important.
Is surgery safe after failed ERCP?
In experienced hands, surgical CBD exploration is an effective treatment for difficult bile duct stones when ERCP is unsuccessful.
When should I consult a surgeon instead of repeating ERCP?
Seek a surgical opinion after failed ERCP, for a large or impacted stone, persistent jaundice, recurrent stones or gallbladder disease requiring surgery.
Why choose Dr. Raman Garg for complex bile duct stones?
Dr. Raman Garg specializes in advanced hepatobiliary and gastrointestinal surgery, including impacted CBD stones, failed ERCP cases and complex biliary procedures.
Patient identity has been withheld to maintain confidentiality. This case is shared for educational purposes only. Individual diagnosis and treatment should always be based on evaluation by a qualified medical professional.
