ERCP with Stent Placement Sample Report

DATE OF PROCEDURE: MM/DD/YYYY

PREOPERATIVE DIAGNOSES:
1. Bile leak.
2. Status post cholecystectomy.

POSTOPERATIVE DIAGNOSES:
1. Bile leak.
2. Status post cholecystectomy.
3. Status post stent placement.
4. Normal pancreatic duct.

OPERATION PERFORMED: ERCP with stent placement.

ANESTHESIA: Monitored anesthesia care and oxygen by nasal cannula.

INDICATIONS FOR PROCEDURE: The patient is a (XX)-year-old Hispanic woman who had a laparoscopic cholecystectomy approximately nine days ago. This was complicated by a bile leak, and she is now undergoing therapeutic ERCP to place a stent.

INSTRUMENT: Olympus JF-140.

DESCRIPTION OF PROCEDURE: After obtaining informed consent, the patient was turned in the prone position and sedated. The duodenoscope was introduced through the bite block into the oropharynx and blindly advanced into the esophagus. The scope was passed through normal-appearing esophagus to the stomach. The gastric pool was aspirated. In the gastric antrum, there was a large collection of food material. This could not be aspirated. The scope was able to be manipulated past this into the distal antrum. The pylorus was identified and appeared normal. The duodenum was intubated, and the scope was passed through the second portion of the duodenum.

Bile flowed freely from a normal-appearing papilla of Vater. This was cannulated. Initial cannulation opacified the pancreatic duct. This was normal. It traveled in a somewhat more cephalad direction than usual. The common bile duct was then effectively cannulated. A bile leak was identified, but the site of leakage could not be seen.

With repeated manipulation of the cannula and attempts to pass the guidewire, we eventually obtained a deep cannulation. It appeared that her distal common bile duct moved in a U or J shape, making it more difficult to pass the guidewire. However, once deep cannulation was obtained, the wire was easily passed into the proximal ducts. The cannula was withdrawn as contrast was injected. No filling defects were identified. A 7 French, 7 cm straight stent was then passed over the guidewire. The proximal end of the stent reached the level of the surgical clips. The stent pusher and guidewire were withdrawn. The stent was placed in excellent position. The scope was withdrawn. The stomach was carefully evaluated as the scope was withdrawn. No additional abnormalities were seen. The patient tolerated the procedure well.

COMPLICATIONS: None at this time.

SPECIMENS: None.

RECOMMENDATIONS:
1. Follow laboratory studies.
2. Check ultrasound and have radiologist aspirate residual fluid in the a.m.
3. Repeat ERCP or EGD in eight weeks to remove the stent.


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