Usefulness and Limitations of the One Step Approach to Managing Biliary Pancreatitis

Ashley Pistorio, MD, Cory Richardson, MD, Heidi Ryan, MD, Charles R St. Hill, MD, MSc, Matthew Johnson, MD, Matthew Ingle, Nathan I Ozobia, MD, FACS. University of Nevada School of Medicine.

INTRODUCTION A safe and accepted approach to managing biliary pancreatitis is to allow the pancreatitis to “cool off” before performing a cholecystectomy with intra-operative cholangiogram (IOC). Another approach is to perform a cholecystectomy within the first 36 hours of admission, unless other medical issues contraindicate surgical intervention. An endoscopic retrograde cholangio-pancreaticogram (ERCP) is performed synchronously or metachronously to ascertain the status of the bile duct. With the UNSOM/UMC Las Vegas experience and success of performing ERCP in the supine position during laparotomies, it became possible to study the usefulness and limitations of intra-operative ERCP in the management of biliary pancreatitis.

METHODS AND PROCEDURES During a four year period, over 200 patients have successfully undergone intra-operative ERCPS [INOPERC] at the time of cholecystectomy. For this study, 20 patients diagnosed with biliary pancreatitis were selected and consented for: Laparoscopic, possible open, cholecystectomy with IOC; ERCP [INOPERC] with papillotomy and stone extraction, and possible insertion of biliary stent. All consented patients were operated on and an IOC obtained. If the IOC was omitted for technical reasons, an ERCP was still performed as long as the pre-op diagnosis was certain for biliary pancreatitis. If the IOC was negative for bile duct pathology, ERCP was omitted. All ERCPs were performed exclusively by the surgical team.

RESULTS The One Step approach to biliary pancreatitis has several limitations, including its limited utility when multiple or large (>2cm) bile duct stones are present as this often requires multiple ERCPs to clear the common bile duct. Also, performance of ERCP is technically more challenging in the supine position. Additionally, equipment and staffing required to perform the laparoscopic cholecystectomy with IOC and ERCP in one anesthesia are potential challenges, but can be easily resolved with properly trained radiology and endoscopy crews and with tolerant anesthesiologists and operating room staff. Overall, the procedure has proven its usefulness because ERCP is better tolerated with general anesthesia than with sedation, and successful completion of the One Step eliminates the need for subsequent ERCP in most cases of biliary pancreatitis. The One Step Lap Chole has been shown in a previous study at UNSOM/UMC to reduce hospital costs and length of stay.

CONCLUSIONS The One Step Laparoscopic Cholecystectomy offers a rational approach to the management of patients with biliary pancreatitis. It has already been shown to reduce hospital costs and can be adapted to the surgical treatment of other obstructing diseases of the biliary tree.

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