2. • Role of intraoperative cholangiography in patients
undergoing laparoscopic cholecystectomy for
acute gallstone pancreatitis: Is MRCP needed?
• Journal: The Annals of The Royal College of
Surgeons of England
• PUBLISHED ON: JULY 3, 2019
3. Introduction
• IOC is sporadically used in patients undergoing
laparoscopic cholecystectomy to delineate common
bile duct anatomy and exclude retained stones.
• In patients with acute gallstone pancreatitis, IOC may
reduce need for preoperative MRCP.
5. • IOC has been shown to be sensitive and
specific at detecting CBD stones as well as
safely delineating biliary anatomy.
• A positive IOC enables surgeon to perform an
immediate CBD exploration, stone clearance
and laparoscopic cholecystectomy in a single
procedure, thereby reducing lengthy time
delays from unnecessary MRCP
6. Hypothesis
• In patients with acute gallstone pancreatitis,
IOC reduces the need for preoperative MRCP.
8. Methodology
• A retrospective study was undertaken of all
patients under-going laparoscopic
cholecystectomy at St James’ University Hospital,
over a 15-year period between October 1998 and
December 2013
• 2215 patients underwent laparoscopic
cholecystectomy between October 1998 and
December 2013
• 113 patients (of whom 77 were women) with a
mean age of 54 years (range 16–88 years) were
diagnosed with acute gallstone pancreatitis.
9. Inclusion criteria
• All patients with a diagnosis of gallstone pancreatitis
who underwent laparoscopic cholecystectomy were
included in the study.
10. Exclusion criteria
• Patients who underwent a preoperative ERCP
were excluded from further analysis as
choledocholithiasis had already been
established and treated.
11. Statistical analysis
• Sample size 113
• Statistical analysis was performed using Prism
version 6.0c (GraphPad Software, La Jolla,
California).
• The Mann–Whitney U test was used to
compare continuous data
• P-value of less than 0.05 was considered
statistically significant.
12. Result
• 2215 patients underwent laparoscopic
cholecystectomy in 15-year period.
• Of these, 113 patients were diagnosed with acute
gallstone pancreatitis, with a mean age of 54 years
• 11 patients had no IOC performed either due to
unavailability of a radiographer or because of
technical issues.
13. • Median time interval between date of
diagnosis of acute gallstone pancreatitis and
laparoscopic cholecystectomy was five days
(range 0–21 days).
14. • 102 patients underwent an IOC.
• In 89 cases (87%), this was found to be
normal.
• 13 patients were found to have
choledocholithiasis at time of laparoscopic
cholecystectomy.
• 11 of these patients were managed
successfully via concomitant CBD exploration
while remaining 2 patients underwent a
postoperative ERCP.
15. • Of the 36 patients who underwent a
preoperative MRCP, 12 of them were shown to
have choledocholithiasis.
• At surgery, 11 of these patients were found to
have a clear duct.
• 4 of the 24 patients with normal preoperative
MRCP findings were shown to have
choledocholithiasis on IOC.
17. Conclusion
• Majority of patients presenting with acute
gallstone pancreatitis managed with
laparoscopic cholecystectomy and IOC,
without requiring a preoperative MRCP.
• Cost savings due to shorter inpatient stays and
reduced use of MRCP.
18. • IOC reduces time between diagnosis of acute
gallstone pancreatitis and laparoscopic
cholecystectomy, enabling timely surgical
management within recommended
guidelines.
19. • 59 patients with symptomatic biliary stones or cholecystitis were recruited
in this study.
• Preoperative MRCP and IOC were performed
• PPV for IOC was 88% and for MRCP was 43%.
• Diagnostic accuracy of IOC and MRCP were 98% and 85% respectively,
suggesting that IOC is much more diagnostically accurate.
20. • 420 who underwent IOC were reviewed and met criteria for
the study.
• 70 patients had preoperative MRCP.
• Accuracy of MRCP when compared with IOC was 70%.
Conclusions
• MRCP has a high rate of false normal results compared with
IOC and is not as accurate as more invasive techniques.
• No need for preoperative MRCP in patients with suspected
choledocholithiasis caused by stones
21. • 425 consecutive patients who underwent IOC during
cholecystectomy were included in this study.
• MRCP was performed preoperatively for bile duct evaluation
in all patients.
• MRCP preoperatively identified 6 (1.4 %) patients with
abnormal biliary systems and 56 with CBD stones, which were
endoscopically removed.
• The success rate of IOC was 93.8 % (399/425).
• Abnormalities of the biliary system were detected in 12
patients (12/399, 3.0 %) and CBD stones in 8 (8/399, 2.0 %).
22. • IOC is indicated even after preoperative
sphincterotomy for CBD stones.
• In this study, it resulted in a 12.5 % incidence
of persistent stones after sphincterotomy.
• IOC plays an additional role in detecting CBD
stones and in revealing abnormalities of biliary
tree in patients whose biliary tree was
preoperatively evaluated by MRCP
23. IAP GUIDELINES
Cholecystectomy during index admission for mild biliary pancreatitis appears
safe
Interval cholecystectomy after mild biliary pancreatitis is associated with a
substantial risk of readmission for recurrent biliary events, especially
recurrent biliary pancreatitis.
Cholecystectomy should be delayed in patients with peripancreatic
collections until collections either resolve or if they persist beyond 6 weeks,
at which time cholecystectomy can be performed safely.
In patients with biliary pancreatitis who have undergone sphincterotomy
and are fit for surgery, cholecystectomy is advised, because ERCP and
sphincterotomy prevent recurrence of biliary pancreatitis but not gallstone
related gallbladder disease, i.e. biliary colic and cholecystitis
