Treatment Options for Patient With Gallstone Pancreatitis

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Treatment Options for Patient With Gallstone Pancreatitis?

Posted 09/23/2002

from Medscape Surgery

Question

A patient with gallstone pancreatitis was initially managed

conservatively. During the same admission she was offered laparoscopic

cholecystectomy. If only a few small stones are found in the common bile

duct (CBD) on intraoperative cholangiogram, what are the treatment

options for this patient?

Muhammad Akram, FCPS, FRCS

Response

from B. Mark Evers, MD, 09/23/2002

There are several treatment options for the patient described in this

question. Options would include laparoscopic CBD exploration,

postoperative endoscopic retrograde cholangiopancreatogram (ERCP) with

sphincterotomy and removal of stones, standard open CBD exploration, or

clinical observation only.[1] Since this patient has been symptomatic,

observation only without further treatment would be risky and probably

would result in recurrent symptoms. Therefore, one option, depending on

the skill of the surgeon, would be laparoscopic CBD exploration by a

transcystic duct exploration or laparoscopic choledochotomy.[1,2] With

laparoscopic transcystic duct exploration, the cystic duct is cannulated

and dilated and then the stones are removed using stone baskets or by

flushing the CBD via a catheter. Success rates of 35% to 87% have been

reported, depending on whether single or multiple stones are encountered.

Choledochotomy with exploration of the CBD can be performed

laparoscopically and is preferred by some surgeons; however, this

technique necessitates laparoscopic suturing and mandates placement of a

T-tube, and there is a potential for longer hospitalization. Another

option would be to perform a postoperative ERCP with stone

extraction.[3,4] The success rate of this technique in experienced hands

has been reported at 90% to 95% and would certainly be a consideration in

the patient described in this question. Finally, if the surgeon is not

comfortable performing laparoscopic CBD procedures and the availability

for ERCP is not present, then a standard open CBD exploration can be

performed.[5]

References

Ponsky JL, Heniford BT, Gersin K. Choledocholithiasis: evolving

intraoperative strategies. Am Surg. 2000;66:262-268.

Crawford DL, EH. Laparoscopic common bile duct exploration.

World J Surg. 1999;23:343-349.

Scotiniotis I, Kochman ML. Endoscopic management of biliary tract

disease. Curr Opin Gastroenterol. 1998;14:417-421.

American Society for Gastrointestinal Endoscopy The role of ERCP in

diseases of the biliary tract and pancreas: guidelines for clinical

application. Gastrointest Endosc. 1999;50:915-920.

RCG. Open operations on the bile duct for stones. Semin Laparosc

Surg. 1995;2:131-139.

About the Panel Members

B. Evers, MD, Professor, Department of Surgery, University of Texas

Medical Branch; staff physician/surgeon, Clinical Department of General

Surgery, University of Texas Medical Branch, Galveston, Texas.