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Laparoscopic approach to the biliary tract in acute necrotizing pancreatitis
Laparoscopic Approach to the Biliary Tract in Acute Necrotizing Pancreatitis NathanielJ,
Soper, M.D.
Gallstones are the most common cause of acute pancreatitis in North America. The pathophysiology of gallstone pancreatitis involves transient or persistent obstruction of the ampulla of Vater by a gallstone and nearly always is associated with an intact gallbladder containing gallstones. The spectrum of severity of pancreatitis ranges from mild edematous pancreatitis that quickly resolves spontaneously to severe life-threatening pancreatitis with pancreatic necrosis and infection. There are numerous controversial issues in the management of acute necrotizing pancreatitis (ANP), not the least of which is the role of laparoscopic therapy. The timing of surgical intervention and cholecystectomy for gallstone pancreatitis has evolved considerably over the past few decades. Delayed cholecystectomy (at a second admission 6 to 8 weeks later) has been supplanted by operation during the initial admission after the acute manifestations of pancreatitis have resolved.‘,? This approach has reduced the likelihood of recurrent pancreatitis and diminished the total duration of hospitalization. Urgent operation within 48 hours of admission for ANP has been shown to worsen outcome and should be av0ided.j Although laparoscopic cholecystectomy has now replaced open cholecystectomy as the “gold standard” of therapy for patients with symptomatic gallstones, the well-established principles described above still apply to patients with gallstone pancreatitis. Several groups+-* have now shown that laparoscopic cholecystectomy is safe and effective for the treatment of patients with gallstone pancreatitis. Increased inflammatory conditions around the gallbladder and porta hepatis may be found in some of these patients, but in our experience this has not led to increased complications or a higher rate of conversion to open operation. Early in the evolution of laparoscopic cholecystectomy, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was used liberally to “clear the bile duct” prior to laparos-
copy. However, with the development of laparoscopic techniques for exploring the bile duct and improved expertise in endoscopic clearance of the duct by ERCP, the role of ERCP has again become more selective. Preoperative ERCP is reserved for patients with severe or unremitting pancreatitis, cholangitis, jaundice, or a definite bile duct stone that has been visualized sonographically. Patients with mild biliary pancreatitis undergo laparoscopic cholecystectomy during the index admission once the pancreatitis has subsided clinically. The aim is to perform laparoscopic cholecystectomy the day before the patient’s anticipated discharge. After decompressing the biliary system by ERCP with sphincterotomy, patients with ANP are managed expectantly. Intravenous antibiotics, total parenteral nutrition, and analgesics are routinely used until the patient improves sufficiently to undergo cholecystectomy, which is generally 2 to 3 weeks after admission. If evidence of infected ANP develops, peripancreatic debridement is required. This operation has traditionally been performed by laparotomy with removal of all infected and necrotic tissue and placement of drains. Recent anecdotal reports suggest that laparoscopic debridement of peripancreatic necrosis may also be feasible.9,10 Cholangiography or intraoperative ultrasonography” should be performed at the time of laparoscopic cholecystectomy in all patients. If a small stone or stones is seen in the common bile duct, an attempt is made to remove it laparoscopically using a transcystic duct approach if conditions are favorable. In the setting of acute gallstone pancreatitis, the common bile duct stones are usually small and the cystic duct is usually dilated as a result of recent stone passage, thus facilitating transcystic duct stone removal. Stones smaller than 2 mm can usually be simply flushed into the duodenum after pharmacologic ampullary dilatation using intravenous glucagon.” Stones larger than this generally require basket extraction, with placement of the basket either under
From the Department of Surgery, Washington University School of Medicine, St. Louis, MO. Correspondence: Nathaniel J. Soper, M.D., Department of Surgery, Washington University School of Medicine, One Barnes Hospital Plaza, Box 8109, St. Louis, MO 63 110. 240
Vol. 5, No. 3 2001
LaparoscopicApproachin ANP
241
Severe Pancreatitis, Cholangitis, or Evidence of CBD Stones on Abdominal Ultrasound
No
Yes
ERCP f ES
Pancreatitis Resolves C-Rapidly
No
Yes
1 ?Evidence
?Contraindications to Laparoscopic Cholecystectomy?
c
Yes
1 Yes
No
I
Operative Debridement, Cholecystectomy With IOC or US f CBDE
No
JOpen Cholecystectomy With IOC or US _+CBDE
f--
CT Scan: of Pancreatic Necrosis?
JLaparoscopic Cholecystectomy With IOC or US
CBD Stones
l
No
I Yes J. Laparoscopic Extraction
-
?Successful
No
Open CBDE
or
k Postoperative ERCP+ES
Yes v 1 Complete Laparoscopic Cholecystectomy
Fig. 1. Management of acute gallstone pancreatitis. CBD = common bile duct exploration; ERCP = endoscopic retrograde cholangiopancreatography; ES = endoscopic sphincterotomy; IOC = intraoperative cholangiography.
fluoroscopic guidance12 or by means of a small (< 10 Fr) choledochoscope. 13,i4 Transcystic duct laparoscopic approaches are used successfully to treat choledocholithiasis in more than 85% of patients in reported series.4Jz-14 Common bile duct stones that are multiple or larger than 6 to 7 mm in diameter are often referred for postoperative ERCP. Alternatively, laparoscopic choledochotomy with direct stone extraction may be performed provided the bile duct is dilated and the surgeon is experienced in laparoscopic
suturing. l5 If expertise in laparoscopic bile duct exploration and ERCP are lacking in a patient with a bile duct stone found during cholangiography, conversion to an open operation is indicated. Given the success of laparoscopic common bile duct exploration and ERCP, it should be possible to manage the majority of patients with gallstone pancreatitis by minimally invasive techniques. Our current algorithm for the management of acute gallstone pancreatitis is shown in Fig. 1.
242
Soper
REFERENCES 1. Ranson JHC. The timing of biliary surgery in acute pancreatitis. Ann Surg 1979; 189:654-663. 2. Stone HH, Fabian TC, Dunlap WE. Gallstone pancreatitis: Biliary tract pathology in relation to time of operation. Ann Surg 1981;194:305-312. 3. Kelly TR, Wagner DS. Gallstone pancreatitis: A prospective randomized trial of the timing of surgery. Surgery 1988;104: 600-605. 4. Soper NJ, Brunt LM, Callery MP, Edmundowicz SA, Ahperti G. Role of laparoscopic cholecystectomy in the management of acute gallstone pancreatitis. Am J Surg 1994;167:42-50. 5. Tate JJT, Lau WY, Li AKC. Laparoscopic cholecystectomy for biliary pancreatitis. Br J Surg 1994;81:720-722. 6. Tang E, Stain SC, Tang G. Timing of laparoscopic surgery in gallstone pancreatitis. Arch Surg 1995;130:496-500. 7. Delorio AV Jr, Vitale GC, Reynolds M, Larson GM. Acute biliary pancreatitis. The role of laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography. Surg Endosc 1995;9:392-396. 8. Ballestra-Lopez C, Bastida-Vila X, Bettonica-Larranaga C, Zaraca F, Catarci M. Laparoscopic management of acute biliary pancreatitis. Surg Endosc 1997; 11:7 18-72 1.
Gastrointestinal
Journal of Surgery
9. Alverdy J, Vargish T, Desai T, Frawley B, Rosen B. Laparoscopic intracavitary debridement of peripancreatic necrosis: Preliminary report and description of the technique. Surgery 2000;127:112-114. 10. Cambiez LP, Denimal FA, Porte HL, Saudemont A, Chanbon JPM, Quandalle PA. Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections. Arch Surg 1998;133:66-72. 11. Wu JS, Dunnegan DL, Soper NJ. The utility of intraoperative ultrasonography for screening the bile duct during laparoscopic cholecystectomy. J GASTROI~TESTSURG 1998;2:50-60. 12. Hunter JG. Laparoscopic transcystic common bile duct exploration. Am J Surg 1992;163:53-58. 13. Carroll BJ, Phillips EH, Rosenthal R, Liberman M, Fallas M. Update on transcystic exploration of the bile duct. Surg Laparosc Endosc 1996;6:453-458. 14. Petelin JB. Laparoscopic approach to common duct pathology. Am J Surg 1993;165:487-491. 15. Dion Y-M, Ratelle R, Morin J, Gravel D. Common bile duct exploration: The place of laparoscopic choledochotomy. Surg Laparosc Endosc 1994;6:419-424.
Soper, M.D.
Gallstones are the most common cause of acute pancreatitis in North America. The pathophysiology of gallstone pancreatitis involves transient or persistent obstruction of the ampulla of Vater by a gallstone and nearly always is associated with an intact gallbladder containing gallstones. The spectrum of severity of pancreatitis ranges from mild edematous pancreatitis that quickly resolves spontaneously to severe life-threatening pancreatitis with pancreatic necrosis and infection. There are numerous controversial issues in the management of acute necrotizing pancreatitis (ANP), not the least of which is the role of laparoscopic therapy. The timing of surgical intervention and cholecystectomy for gallstone pancreatitis has evolved considerably over the past few decades. Delayed cholecystectomy (at a second admission 6 to 8 weeks later) has been supplanted by operation during the initial admission after the acute manifestations of pancreatitis have resolved.‘,? This approach has reduced the likelihood of recurrent pancreatitis and diminished the total duration of hospitalization. Urgent operation within 48 hours of admission for ANP has been shown to worsen outcome and should be av0ided.j Although laparoscopic cholecystectomy has now replaced open cholecystectomy as the “gold standard” of therapy for patients with symptomatic gallstones, the well-established principles described above still apply to patients with gallstone pancreatitis. Several groups+-* have now shown that laparoscopic cholecystectomy is safe and effective for the treatment of patients with gallstone pancreatitis. Increased inflammatory conditions around the gallbladder and porta hepatis may be found in some of these patients, but in our experience this has not led to increased complications or a higher rate of conversion to open operation. Early in the evolution of laparoscopic cholecystectomy, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was used liberally to “clear the bile duct” prior to laparos-
copy. However, with the development of laparoscopic techniques for exploring the bile duct and improved expertise in endoscopic clearance of the duct by ERCP, the role of ERCP has again become more selective. Preoperative ERCP is reserved for patients with severe or unremitting pancreatitis, cholangitis, jaundice, or a definite bile duct stone that has been visualized sonographically. Patients with mild biliary pancreatitis undergo laparoscopic cholecystectomy during the index admission once the pancreatitis has subsided clinically. The aim is to perform laparoscopic cholecystectomy the day before the patient’s anticipated discharge. After decompressing the biliary system by ERCP with sphincterotomy, patients with ANP are managed expectantly. Intravenous antibiotics, total parenteral nutrition, and analgesics are routinely used until the patient improves sufficiently to undergo cholecystectomy, which is generally 2 to 3 weeks after admission. If evidence of infected ANP develops, peripancreatic debridement is required. This operation has traditionally been performed by laparotomy with removal of all infected and necrotic tissue and placement of drains. Recent anecdotal reports suggest that laparoscopic debridement of peripancreatic necrosis may also be feasible.9,10 Cholangiography or intraoperative ultrasonography” should be performed at the time of laparoscopic cholecystectomy in all patients. If a small stone or stones is seen in the common bile duct, an attempt is made to remove it laparoscopically using a transcystic duct approach if conditions are favorable. In the setting of acute gallstone pancreatitis, the common bile duct stones are usually small and the cystic duct is usually dilated as a result of recent stone passage, thus facilitating transcystic duct stone removal. Stones smaller than 2 mm can usually be simply flushed into the duodenum after pharmacologic ampullary dilatation using intravenous glucagon.” Stones larger than this generally require basket extraction, with placement of the basket either under
From the Department of Surgery, Washington University School of Medicine, St. Louis, MO. Correspondence: Nathaniel J. Soper, M.D., Department of Surgery, Washington University School of Medicine, One Barnes Hospital Plaza, Box 8109, St. Louis, MO 63 110. 240
Vol. 5, No. 3 2001
LaparoscopicApproachin ANP
241
Severe Pancreatitis, Cholangitis, or Evidence of CBD Stones on Abdominal Ultrasound
No
Yes
ERCP f ES
Pancreatitis Resolves C-Rapidly
No
Yes
1 ?Evidence
?Contraindications to Laparoscopic Cholecystectomy?
c
Yes
1 Yes
No
I
Operative Debridement, Cholecystectomy With IOC or US f CBDE
No
JOpen Cholecystectomy With IOC or US _+CBDE
f--
CT Scan: of Pancreatic Necrosis?
JLaparoscopic Cholecystectomy With IOC or US
CBD Stones
l
No
I Yes J. Laparoscopic Extraction
-
?Successful
No
Open CBDE
or
k Postoperative ERCP+ES
Yes v 1 Complete Laparoscopic Cholecystectomy
Fig. 1. Management of acute gallstone pancreatitis. CBD = common bile duct exploration; ERCP = endoscopic retrograde cholangiopancreatography; ES = endoscopic sphincterotomy; IOC = intraoperative cholangiography.
fluoroscopic guidance12 or by means of a small (< 10 Fr) choledochoscope. 13,i4 Transcystic duct laparoscopic approaches are used successfully to treat choledocholithiasis in more than 85% of patients in reported series.4Jz-14 Common bile duct stones that are multiple or larger than 6 to 7 mm in diameter are often referred for postoperative ERCP. Alternatively, laparoscopic choledochotomy with direct stone extraction may be performed provided the bile duct is dilated and the surgeon is experienced in laparoscopic
suturing. l5 If expertise in laparoscopic bile duct exploration and ERCP are lacking in a patient with a bile duct stone found during cholangiography, conversion to an open operation is indicated. Given the success of laparoscopic common bile duct exploration and ERCP, it should be possible to manage the majority of patients with gallstone pancreatitis by minimally invasive techniques. Our current algorithm for the management of acute gallstone pancreatitis is shown in Fig. 1.
242
Soper
REFERENCES 1. Ranson JHC. The timing of biliary surgery in acute pancreatitis. Ann Surg 1979; 189:654-663. 2. Stone HH, Fabian TC, Dunlap WE. Gallstone pancreatitis: Biliary tract pathology in relation to time of operation. Ann Surg 1981;194:305-312. 3. Kelly TR, Wagner DS. Gallstone pancreatitis: A prospective randomized trial of the timing of surgery. Surgery 1988;104: 600-605. 4. Soper NJ, Brunt LM, Callery MP, Edmundowicz SA, Ahperti G. Role of laparoscopic cholecystectomy in the management of acute gallstone pancreatitis. Am J Surg 1994;167:42-50. 5. Tate JJT, Lau WY, Li AKC. Laparoscopic cholecystectomy for biliary pancreatitis. Br J Surg 1994;81:720-722. 6. Tang E, Stain SC, Tang G. Timing of laparoscopic surgery in gallstone pancreatitis. Arch Surg 1995;130:496-500. 7. Delorio AV Jr, Vitale GC, Reynolds M, Larson GM. Acute biliary pancreatitis. The role of laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography. Surg Endosc 1995;9:392-396. 8. Ballestra-Lopez C, Bastida-Vila X, Bettonica-Larranaga C, Zaraca F, Catarci M. Laparoscopic management of acute biliary pancreatitis. Surg Endosc 1997; 11:7 18-72 1.
Gastrointestinal
Journal of Surgery
9. Alverdy J, Vargish T, Desai T, Frawley B, Rosen B. Laparoscopic intracavitary debridement of peripancreatic necrosis: Preliminary report and description of the technique. Surgery 2000;127:112-114. 10. Cambiez LP, Denimal FA, Porte HL, Saudemont A, Chanbon JPM, Quandalle PA. Retroperitoneal approach and endoscopic management of peripancreatic necrosis collections. Arch Surg 1998;133:66-72. 11. Wu JS, Dunnegan DL, Soper NJ. The utility of intraoperative ultrasonography for screening the bile duct during laparoscopic cholecystectomy. J GASTROI~TESTSURG 1998;2:50-60. 12. Hunter JG. Laparoscopic transcystic common bile duct exploration. Am J Surg 1992;163:53-58. 13. Carroll BJ, Phillips EH, Rosenthal R, Liberman M, Fallas M. Update on transcystic exploration of the bile duct. Surg Laparosc Endosc 1996;6:453-458. 14. Petelin JB. Laparoscopic approach to common duct pathology. Am J Surg 1993;165:487-491. 15. Dion Y-M, Ratelle R, Morin J, Gravel D. Common bile duct exploration: The place of laparoscopic choledochotomy. Surg Laparosc Endosc 1994;6:419-424.