North Texas GME Research Forum 2024



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North Texas


Medical City Plano


General Surgery

Document Type


Publication Date



simulation, trauma, graduate medical education, simulation training


Medical Education | Medicine and Health Sciences | Surgery | Trauma


Introduction: According to the American Society of Gastroenterology Endoscopy (ASGE), choledocholithiasis is defined as the presence of gallstones in biliary tree. Choledocholithiasis is concomitantly present in approximately 1 to 10 percent of patients with cholelithiasis. Choledocholithiasis can be described as small <15 >mm, large >15 mm, and difficult due to anatomic location, impaction, or unusual hardness/ shape. Choledocholithiasis is managed endoscopically with large balloon papillary dilation, cholangioscopy-guided intraductal laser and electrohydraulic lithotripsy (EHL), and escalation to laparoscopic common bile duct exploration, if endoscopic procedures fail. Thus far, there are sparse studies that show the requirement of choledochotomy in large and difficult choledocholithiasis management. Case: A 55-year-old African-American female with hypertension presented with colicky epigastric and right upper quadrant abdominal pain intermittently for 10 years, which was self-resolving. She presented as hemodynamically stable, mildly leukocytic with elevated liver function tests and dilated common bile duct (CBD). Abdominal ultrasound and Computed Tomography Angiography suggested presence of multiple cholelithiasis and choledocholithiasis. She underwent Endoscopic Retrograde Cholangiopancreatography (ERCP) and biliary sphincterotomy that demonstrated multiple large choledocholithiasis from ampulla of Vater to hilum of liver (Figure 1). No stones were removed due to the large size and hard-to-reach locations. Initially, a 7 cm plastic biliary stent encapsulating the existing stones was placed 6 cm into the CBD. Within three days, the initial biliary stent was found to be partially occluded, and a new stent needed to be placed. Biliary sludge and one stone were removed while multiple stones remained. Endoscopist performed direct visualization of ducts with SPY, which demonstrated multiple stones in the lower third of CBD with the largest measuring 1.8 cm in size. Patient underwent Laparoscopic Cholecystectomy with CBD exploration and Lithotripsy, which was converted into a choledochotomy by a hepatobiliary surgeon. The remaining stones were successfully removed. Post-operatively, the patient was optimized with pain control and Piperacillin/Tazobactam for antibiotic coverage, and discharged 3 days later without postoperative complications. Discussion: Current guidelines published in ASGE, do not explicitly recommend performing surgical intervention of large and difficult choledocholithiasis with choledochotomy. However, this case highlights the necessity for surgical escalation of care for the management of large and difficult CBD stones. Ultimately, more case studies will need to be reported in order to support the utilization of a multidisciplinary approach towards the successful management of large and difficult choledocholithiasis.

Original Publisher

HCA Healthcare Graduate Medical Education


2nd Place - Quality Improvement Category

Multidisciplinary Simulation-Based Trauma Education for General Surgery Interns



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