Obstructive lithiasis of the lower bile duct discovered four decades after cholecystectomy and its management by ideal choledochotomy: a case report.

BACKGROUND: Residual lithiasis is the presence of stones in the common bile duct, ignored after one or more biliary interventions. We report an atypical case of chronic symptomatic lithiasis of the lower bile duct occurring 41 years after biliary surgery, managed successfully by ideal choledochotomy. CASE PRESENTATION: A 68-year-old Black African female with several past laparotomies including a cholecystectomy forty-one years ago presented with hepatic colic-type pain that had been intermittent for several years but worsened recently. Her clinical, biological, and imaging test assessments were suggestive of a residual obstructive lithiasis of the lower common bile duct. Through an open right subcostal laparotomy approach, a dilated bile duct of approximately 3 cm was found and managed by transverse choledochotomy in which the stone was extracted in retrograde manner. After confirmation of disobstruction, a primitive bile duct suture without biliary drainage was performed and a tubular drain was positioned under the liver. The postoperative course was uneventful at follow-up of 30 days. CONCLUSION: Residual choledocholithiasis can be avoided. We performed an ideal choledochotomy, of which the follow-up was simple.

Brachiocephalic A-V fistula through the median cubital vein; A reliable option to failure of forearm fistulas. A case report from CHU Yaoundé.

INTRODUCTION: Renal replacement therapy in end-stage kidney disease relies on dialysis in low-income countries. This maintenance treatment needs a reliable vascular access and is done through central venous catheter or creation of A-V fistulas. Several types of A-V fistulas can be done but due to some individual conditions, those possibilities may be exhausted rapidly. CASE PRESENTATION: A 31 year old female was diagnosed with an end stage renal disease for which she was prescribed maintenance dialysis. She first denied her condition and went to traditional healer. After some months her clinical state worsened and she was dialyse with catheter and refer to us for A-V fistula construction. The first two attempts on the forearm failed and we found small radial artery both proximally and distally on the left forearm. We finally did a left brachiocephalic fistula with initial retrograde flow on the median cubital vein. DISCUSSION: Despite arm base fistula may be theoretically easy to build because of bigger size vessels, brachiobasilic fistula may be less effective due to difficult venipuncture. Brachiocephalic fistula through median cubital vein may be more effective option with no further procedure needed. CONCLUSION: Brachiocephalic fistula should be considered as option in vascular access especially when a reliable option is needed after previous attempt failure.