A case of late presentation of recurrent primary choledocholithiasis 30 years post-cholecystectomy: Presentation and management

Acute cholangitis typically occurs secondary to biliary obstruction and bile stasis. While the most common cause is secondary choledocholithiasis (i.e., stones form in the gallbladder and are expelled into the common bile duct), there is little information on primary choledocholithiasis as the principal source of this obstruction. Furthermore, it is particularly rare to see symptomatic choledocholithiasis years to decades later in patients who previously underwent cholecystectomy. We report a complex case of a 75-year-old woman who presented to the emergency department with a 3 to 4-day history of abdominal pain, nausea, generalized weakness, fever, and shortness of breath. She had septic cholangitis due to primary choledocholithiasis 30 years post-cholecystectomy and numerous other comorbidities that increased the complexity of her case. Endoscopic retrograde cholangiopancreatography (ERCP) was attempted to remove the stone but was unsuccessful due to duodenal diverticula. Eventually, this patient underwent common bile duct exploration using a robot-assisted approach. A 2 cm stone at the distal common bile duct was removed, and her clinical status dramatically improved. The efficiency and increased fine control of a robot-assisted approach introduces our idea that this approach should be an alternative management option for minimally invasive common bile duct exploration in patients who have high-risk comorbidities and failed ERCP. Keywords: Acute cholangitis, primary choledocholithiasis, recurrent choledocholithiasis, post-cholecystectomy, robotic-assisted common bile duct exploration