Xanthomatosis and extreme hypercholesterolemia after laparoscopic cholecystectomy. Recovery following surgery of iatrogenous stenosis of common bile duct

Introduction: Hypercholesterolemia and xanthomatosis are known complications of chronic cholestasis. This is the first report on xanthomatosis and severe hypercholesterolemia caused by common bile duct stenosis following laparoscopic cholecystectomy. Case report: Laparoscopic cholecystectomy was performed in a 32-year old woman because of numerous tiny gallstones. Bile leakage was observed in the early postoperative period which stopped spontaneously. Six months later itching, progressively increasing serum bilirubin level, cholestasis syndrome, xanthelasma and widespread eruptive xanthomatosis developed in a few months. The cholesterol level was extremely high (92,3 mmol/l), while the triglycerid level was normal. Though the ultrasound and the cholangio-MR did not showed any dilatation of bile ducts, the ERCP verified a 2mm long, hair's-breadth thin stenosis at the level of cystic duct. Primary biliary cirrhosis and primary sclerosing cholangitis were excluded, no evidence for familial hypercholesterolemia was found. Choledocho-jejunostomy was performed and the patient became complaint- and symptom-free within two months. All xanthomas disappeared, the extremely high cholesterol level gradually decreased to the normal level, and all the laboratory data became normal. The anticholesterol antibody level was undetectable at presentation, but later reached the level of the healthy controls. Conclusion: The presented case is an example of laparoscopic cholecystectomy caused bile duct stenosis with extrahepatic cholestasis induced xanthomatosis and severe hypercholesterolemia. The bile leakage as early complication of bile duct damage may predict the later developed stenosis. Even severe xanthomatosis and extreme hypercholesterolemia can be totally reversible following elimination of biliary obstacle.