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Miscellaneous Ask The Expert
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, Phillips 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.
Russell 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.