Endoscopic Retrograde Pancreatography and Laparoscopic Cholecystectomy. TEAM 1 Janix M. De Guzman, MD Presentor

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1 Endoscopic Retrograde Pancreatography and Laparoscopic Cholecystectomy TEAM 1 Janix M. De Guzman, MD Presentor

2 Premise 40F Jaundice Abdominal pain US finding of gallstones with apparently normal common bile duct Right upper quadrant tenderness

3 CLINICAL DIAGNOSIS Obstructive jaundice secondary to CBD Stone with cholangitis CERTAINTY 80% Obstructive jaundice secondary to CBD Stone 20%

4 Acute Cholangitis Gallstone Abdominal Pain Jaundice Right Upper Quadrant Tenderness diagnosis of acute cholangitis is often made clinically A normal ultrasound does not rule out cholangitis

5 Goals of Treatment Relieve bile duct obstruction Bliary drainage

6 Treatment Option Treatment Benefit Risk Cost Availability ERCP SR=71-98% CBD Clearance Mortality Rate = 10% -bleeding -perforation -pancreatitis *12-15,000 pesos at Metrop olitan Hospital Not availab le at OMMC *2-3,000 pesos at PGH

7 All patients with ascending cholangitis require biliary drainage. Timing urgent biliary decompression Approximately 10% to 15% of patients fail to respond medically (within 12 to 24 hours) deteriorate after initial medical therapy and these patients need semi-electively during the same admission (and ideally within 72 hours). In patients who respond to medical therapy

8 Endoscopic retrograde cholangiopancreatography (ERCP) highly accurate for determining the cause of biliary obstruction allows appropriate intervention where required potential for complications and availability of accurate noninvasive imaging ERCP should not be used solely as a diagnostic modality should be used when the likelihood of intervention is high, as is often the case in patients with clinically suspected cholangitis

9 Endoscopic retrograde cholangiopancreatography (ERCP) potential complications ERCP should not be used solely as a diagnostic modality should be used when the likelihood of intervention is high, as is often the case in patients with clinically suspected cholangitis

10 Management of the gallbladder after bile duct clearance Cholecystectomy RATIONALE: Prevent recurrence and further biliary complication.

11 Option Treatm ent Benefit Risk Cost Availa bility Able to achieve goal Mortality rate = % Morbidity = 5-6%% post-op =15-20% intraop Conversion Rate = 20% Laparoscopic surgery -complications of anesthesia -bleeding -iatrogenic injury to biliary ducts -trocar and needle insufflation injuries *40-60,00 0 pesos in private hospit als Not availab le at OMMC

12 Laparoscopic Cholecystectomy safe and feasible option can be done within 48 to 72 hours of presentation (early surgery) reduced conversion rates in the early surgery group when compared with the interval surgery group reduced hospital stay in the early surgery group.

13 References 1. Yusoff I, Barkun J, Barkun A. Diagnosis and management of cholecystitis and cholangitis. Gastroent Clin 2003; 32(4) 2. Hanau LH, Steigbigel NH. Acute (ascending) cholangitis. Infect Dis Clin North Am 2000;14: Lai EC, Tam PC, Paterson IA, et al. Emergency surgery for severe acute cholangitis: the high-risk patients. Ann Surg 1990;211: Mark D, Flamm C, Aronson N. Evidence-based assessment of diagnostic modalities for common bile duct stones. Gastroint End. 2002; 56 (6)

14 References: 5. Lai PB, Kwong KH, Leung KL, et al. Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Br J Surg 1998;85: Lo CM, Liu CL, Fan ST, Lai EC, Wong J. Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis. Ann Surg 1998;227: Chandler CF, Lane JS, Ferguson P, Thompson JE, Ashley SW. Prospective evaluation of early versus delayed laparoscopic cholecystectomy for treatment of acute cholecystitis. Am Surg 2000;66:

15 References: 8. Lazăr F, Duţă C, Bordoş D. Difficult laparoscopic cholecystectomy. 2001; 96(3):

Setting The study setting was hospital. The economic analysis was carried out in California, USA.

Setting The study setting was hospital. The economic analysis was carried out in California, USA. Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate gallstone pancreatitis: a prospective randomized trial Chang L, Lo S, Stabile B E, Lewis R J, Toosie