What is the best option to manage a patient with calculous obstructive jaundice and a markedly impacted large stone at the common bile duct (CBD) end, who has failed endoscopic retrograde cholangiopancreatography (ERCP) and has elevated bilirubin, liver function tests (LFT), and alkaline phosphatase (ALP)?

Management of Calculous Obstructive Jaundice with Failed ERCP

For a patient with calculous obstructive jaundice and a markedly impacted large stone at the CBD end who has failed ERCP and has persistently elevated liver function tests, choledochotomy with T-tube drainage is the best option.

Rationale for Surgical Management

When ERCP fails to extract an impacted CBD stone, surgical intervention becomes necessary to resolve the biliary obstruction and prevent further complications. The evidence supports surgical management in this scenario:

• According to the ACR Appropriateness Criteria, surgical CBD exploration is indicated when stones cannot be managed non-surgically 1
• The British Society of Gastroenterology guidelines indicate that laparoscopic bile duct exploration is an appropriate technique for CBDS removal with high success rates 1

Management Algorithm

1. Evaluate Failed ERCP Scenario

• Assess the reason for ERCP failure (in this case, markedly impacted large stone)
• Review laboratory values (elevated bilirubin, LFTs, ALP) indicating ongoing obstruction
• Consider stone size and location (distal CBD impaction)

2. Consider Alternative Non-Surgical Options

• Repeat ERCP with Advanced Techniques: While another ERCP attempt could be considered, the likelihood of success is low with a markedly impacted large stone that already failed initial ERCP 1
• Rendezvous Technique: A combined percutaneous-endoscopic approach could be considered but is more complex and requires specific expertise 1

3. Surgical Management Options

• Choledochotomy with T-tube drainage (Option D): Most appropriate for this case

  • Allows direct access to the impacted stone
  • Provides immediate decompression of the biliary tree
  • T-tube allows post-operative cholangiography to confirm duct clearance
  • Success rates of 95% reported for surgical CBD exploration 1

• Choledochojejunostomy/Hepaticojejunostomy (Options B/C): These are more extensive biliary bypass procedures typically reserved for malignant obstruction or benign strictures rather than stone disease 1

Technical Considerations for Choledochotomy

• Can be performed via open or laparoscopic approach depending on surgeon expertise
• For laparoscopic approach, success rates up to 95% have been reported 1
• T-tube placement provides controlled biliary drainage and allows for:
  • Post-operative cholangiography to confirm duct clearance
  • Access for potential stone extraction if residual stones are present
  • Gradual healing of the choledochotomy

Potential Complications and Their Management

• Bile leak (reported in 14.6% of choledochotomy cases) 2
• Retained stones (2.4-4.4%) 2
• T-tube related complications
• Wound infection

Follow-up Care

• T-tube cholangiogram before removal (typically 7-14 days post-op)
• Monitor liver function tests for normalization
• Consider cholecystectomy if not already performed
• Long-term follow-up to ensure no recurrence of stones

Special Considerations

• For patients with prohibitive surgical risk, biliary stenting as a temporizing measure could be considered, but this is not ideal for definitive management of large impacted stones 1
• Laparoscopic CBD exploration may be preferable to endoscopic duct clearance in patients with wide CBD (>9mm) 1

In this specific case of a markedly impacted large CBD stone with failed ERCP and persistent abnormal liver function tests, choledochotomy with T-tube drainage offers the most direct and effective approach to resolve the obstruction and prevent further complications.