The Practicing Endoscopist | Clinical Reference
Clinical Reference: Post-IOC Pancreatitis After CBD Exploration and Papillary Balloon Dilation
Diagnostic Evaluation & Protocol
1
Identify IOC Findings (Panel A)
Intraoperative cholangiogram shows multiple filling defects within the common bile duct, prompting CBD exploration.
2
Explore the CBD (Panel B)
Use SpyGlass cholangioscopy to visualize stones during laparoscopic common bile duct exploration.
3
Complete Stone Removal (Panel C)
Clear CBD stones, advance a guidewire across the papilla into the duodenum, and perform 8 mm papillary balloon dilation.
4
Monitor Post-Procedure
At 24 hours, assess for epigastric pain radiating to the back and check lipase if pancreatitis is suspected.
5
Recognize the Risk Profile
Acute pancreatitis after laparoscopic IOC and CBD exploration is rare but not negligible. Papillary manipulation still carries inherent risk.
Figure 1: (A) Common bile duct with multiple filling defects on IOC. (B) During endoscopic exploration. (C) After stone removal.
Case Presentation
- Patient: 45-year-old male with acute cholecystitis.
- Procedure: Laparoscopic cholecystectomy with IOC, CBD exploration, stone removal, and 8 mm papillary balloon dilation.
- Post-OP: At 24 hours, epigastric pain radiating to the back with lipase 750 IU/L.
- Diagnosis: Acute pancreatitis following laparoscopic IOC with CBD exploration and papillary balloon dilation.
Clinical Pearls
Incidence: In a 447-patient series, 20 patients (4.5%) developed acute pancreatitis after laparoscopic transcystic CBD exploration.
Perceived Safety: Laparoscopic CBD exploration is often considered lower risk than ERCP, but papillary manipulation is not risk-free.
Investigation Trigger: Elevated lipase and characteristic abdominal pain post-procedure warrant workup for pancreatitis.
Awareness Gap: Many textbooks underlist IOC and papillary balloon dilation as pancreatitis triggers.