Acute Pancreatitis Following Laparoscopic Intraoperative Cholangiogram and Exploration

CASE REPORT

Keywords: acute pancreatitis; intraoperative cholangiogram; common bile duct exploration; laparoscopic cholecystectomy; papillary balloon dilation; choledocholithiasis; SpyGlass cholangioscopy; post-procedural pancreatitis; ERCP alternative; biliary intervention complication

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Clinical History

A 45-year-old male patient presented with acute cholecystitis. He underwent laparoscopic cholecystectomy with intraoperative cholangiogram (IOC). The cholangiogram revealed multiple filling defects within the common bile duct, prompting the decision for intraoperative CBD exploration. A SpyGlass cholangioscope was utilized for direct visualization of the CBD, confirming the presence of multiple stones. Stone removal was performed, a guidewire was advanced across the papilla into the duodenum, and balloon dilation of the papilla was performed using an 8 mm balloon. Twenty-four hours postoperatively, the patient developed epigastric abdominal pain radiating to the back with an elevated lipase of 750 IU/L, consistent with a diagnosis of acute pancreatitis.

Discussion

Acute pancreatitis following intraoperative cholangiogram with common bile duct exploration is generally considered to have a very low incidence. Many institutions perform intraoperative cholangiography and CBD 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 and may be more frequent than traditionally perceived.

The mechanism of pancreatitis in this setting is likely related to papillary manipulation — specifically, the passage of a guidewire across the papilla and subsequent balloon dilation. This instrumentation can cause papillary edema, transient obstruction of the pancreatic duct orifice, and reflux of contrast or bile into the pancreatic duct. These are the same mechanisms implicated in post-ERCP pancreatitis, and it follows that any procedure involving papillary instrumentation — whether performed endoscopically or laparoscopically — carries a similar risk.

A retrospective study by 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 confirmed acute pancreatitis. One patient developed severe necrotizing pancreatitis. This incidence of 4.5% is comparable to post-ERCP pancreatitis rates reported in the literature, which challenges the prevailing assumption that laparoscopic CBD exploration is inherently safer with regard to pancreatitis risk.

This case serves as an important reminder that acute pancreatitis should be considered in the differential diagnosis of any patient presenting with abdominal pain and elevated pancreatic enzymes after laparoscopic biliary interventions. The key clinical indicator — epigastric pain radiating to the back with lipase elevation ≥3 times the upper limit of normal within 24 hours of the procedure — should prompt the same diagnostic and management pathway as post-ERCP pancreatitis, including aggressive fluid resuscitation, pain management, and monitoring for complications.