Acute Pancreatitis Following Laparoscopic Intraoperative Cholangiogram and Exploration

CASE REPORT

Klaus Mönkemüller, MD, PhD, Professor of Medicine, Department of Gastroenterology, Virginia Tech Carilion School of Medicine

Final Diagnosis

Acute pancreatitis following laparoscopic intraoperative cholangiogram with common bile duct exploration and balloon dilation of the papilla.

Patient Demographics

A 45-year-old male patient.

Clinical History

The patient presented with acute cholecystitis. He underwent laparoscopic cholecystectomy with Intraoperative cholangiogram (IOC) and common bile duct exploration after the identification of multiple filling defects within the CBD. Twenty-four hours post-OP, the patient developed epigastric abdominal pain radiating to the back with an elevated lipase of 750 IU/l, consistent with acute pancreatitis.

Endoscopic Findings

Multiple stones were visualized during exploration of the common bile duct.

Endoscopic Technique

1. A laparoscopic cholecystectomy was performed.
2. Multiple filling defects were identified, prompting the decision for common bile duct exploration.
3. A SpyGlass cholangioscope was utilized for exploration of the common bile duct, revealing multiple stones.
4. Stone removal was performed.
5. A guidewire was advanced across the papilla into the duodenum.
6. Balloon dilation of the papilla was performed using an 8 mm balloon.

Discussion

Acute pancreatitis occurring after an intraoperative cholangiogram with common bile duct exploration is generally considered to have a very low incidence. Many institutions perform intraoperative cholangiography and common bile duct exploration with the belief that this approach carries a lower risk of pancreatitis compared to endoscopic retrograde cholangiopancreatography (ERCP). Furthermore, many gastroenterology textbooks do not list intraoperative cholangiogram or balloon dilation of the papilla as causes of pancreatitis. However, there is evidence to suggest that this complication can occur.

A retrospective study by Matias Czerwonko, et al., published in the World Journal of Surgery in 2018, analyzed 447 patients who underwent laparoscopic transcystic common bile duct exploration between 2007 and 2017. Of these, 70 patients developed post-procedure hyperamylasemia, and 20 patients (4.5%) developed acute pancreatitis, confirmed clinically, radiologically, and by laboratory work. One patient developed severe necrotizing pancreatitis. This study highlights that the risk of acute pancreatitis after intraoperative cholangiogram and common bile duct exploration is not insignificant, and clinicians should be aware of this potential complication.

Key Learning Points

1. Acute pancreatitis is a rare but recognized complication of laparoscopic intraoperative cholangiogram and common bile duct exploration.
2. The incidence of pancreatitis following this procedure may be higher than traditionally perceived.
3. Clinicians should maintain awareness of acute pancreatitis as a potential adverse event after intraoperative bile duct interventions.
4. Elevated lipase and characteristic abdominal pain post-procedure warrant investigation for pancreatitis, even after laparoscopic common bile duct exploration.
5. While often considered safer than ERCP in terms of pancreatitis risk, laparoscopic approaches involving papillary manipulation are not entirely without risk.

References

1. Morgan S, Traverso LW. Intraoperative cholangiography and post operative pancreatitis. Surf Endosc 2000;14:264-6.
2. Czerwenko M, et al. Postoperative pancreatitis after laparoscopic transcystic common bile duct exploration. World J Surg. 2018;42(8):2527-2533.