Cholecystectomy

[naturalgut]

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In a setting of long standing chronic pancreatitis of unknown etiology where the pancreas appears normal on laparotomy, is it common to perform a cholecystectomy despite there being no evidence of stones on any prior investigations (other than raised LFTs suggesting a possible cholestatic pattern)?

 

[San_Juan_Sun]

In a setting of long standing chronic pancreatitis of unknown etiology where the pancreas appears normal on laparotomy, is it common to perform a cholecystectomy despite there being no evidence of stones on any prior investigations (other than raised LFTs suggesting a possible cholestatic pattern)?

Why did you do a laparotomy for chronic pancreatitis?

 

[jhonny depp]

Chronic pancreatitis is mostly alcohol related, If the pancreas was normal, it obviously wasnt pancreatitis. Was the laparotomy performed for some other reason? Pancreatic surgery in the setting of chronic pancreatitis is only advocated if there is constant pain or malabsorbtion.
Gall bladder sludge can cause pancreatitis but if the gallbladder is normal there is no need for cholecystectomy.

 

[logistic]

cholestatic LFTs and episode of pancreatitis = passed stones

 

[naturalgut]

Thanks for the replies 👍. I've talked to the surgical team and they provided an explanation.

 

[dr.evil]

Ultrasound is 90-95% accurate for gallstones which lends a 5-10% missed stone diagnosis. Our GI guys push us to perform cholecystectomy for pancreatitis in the abscence of alcoholism. In most patients, it's hard to disagree with them. I just warn the patients that this may or may not be the cause and, although low, the operation has its risks.

 

[San_Juan_Sun]

Ultrasound is 90-95% accurate for gallstones which lends a 5-10% missed stone diagnosis. Our GI guys push us to perform cholecystectomy for pancreatitis in the abscence of alcoholism. In most patients, it's hard to disagree with them. I just warn the patients that this may or may not be the cause and, although low, the operation has its risks.

Do they push for ERCP before you do the chole? Or do you do IOCs in these cases?

 

[dr.evil]

IOCs with all. Most of us do IOCs with all cases of pancreatitis, acute cholecystitis, elevated bilirubin levels.

 

[Celiac Plexus]

IOCs with all. Most of us do IOCs with all cases of pancreatitis, acute cholecystitis, elevated bilirubin levels.

Just curious, what is the rationale for doing IOCs on all acute cholecystitis cases?

 

[San_Juan_Sun]

IOCs with all. Most of us do IOCs with all cases of pancreatitis, acute cholecystitis, elevated bilirubin levels.

Interesting. I'm sure it caries by hospital system, region, community vs academic, etc. My attendings typically have a deal worked out with GI where they get an ERCP w/ papillotomy on HD #1, and lap chole HD #2. Very few IOCs.

 

[dr.evil]

Absolutely hospital/region dependent. Our GI guys are not happy with an ERCP consult unless they are absolutely sure there is a stone that we can't get out laparoscopically. In the private world, ERCP doesn't pay worth a crap, has higher complication rate, and is time intensive at times.

Acute cholecystitis IOCs are variable amongst surgeons for sure. We who do them, do them for 2 reasons usually: Verify anatomy in an acutely inflamed area, and assure no outlet obstruction or stone as cholecystitis is usually caused by obstruction of a stone (albeit usually just of the cystic duct). We clip the cystic duct but how can I be convinced that there is not a stone obstructing the cystic duct distal to my clip that could then go into the CBD?

I don't know. It may be overkill but we surgeons have our ways and tend to stick by them. I've yet to regret doing an IOC.