70 year old male hospitalized in small rural hospital with severe pancreatitis. He was not improving. His initial amylase was elevated to 600. His bili was elevated to 5.1. LFTs improved, but WBC worsened to 25,000. He was transferred to us. A diagnosis of biliary pancreatitis was made. He exhibited RUQ and epigastric fullness and tenderness on physical exam. Patient was taken to the OR where he underwent LC with IOC. A markedly distended gall bladder with severe cholesterolosis was removed. IOC demonstrated a normal CBD with good flow of contrast into the duodenum and the ability for the balloon cholangiocatheter to readily cross the ampulla into the duodenum was demonstrated. The pancreas showed marked edema and swelling. Soaponification (fat necrosis) was noted in scattered areas of the upper abdomen. Postoperatively some clinical improvement was evident, however the WBC elevated more to 34000, and the alkaline phosphatase worsened to 500 - 600 range. Serial CT scans were done, but showed only a markedly edematous pancreas and possibly early pseudocyst development. Patient was treated with IV imipenem and TPN. Temperatures showed fever up to 102 degrees. Dilation of the biliary system was noted on the later CT scans, and the question of a CBD stone was raised by radiology on the IOC. An MR cholangiogram was done showing an l.0cm stone in the CBD and a reverse meniscus sign. An attempt at ERCP was made, but the ampulla could not be cannulated secondary to edema and distortion caused by the inflamed pancreas.
A decision to return the patient to surgery for LCBDE was made. LCBDE could not be accomplished secondary to adhesions in the RUQ from pancreatitis and previous LC. Conversion to open CBDE was necessary. The CBD was identified. Intraoperative cholangiogram showed dilated proximal bile ducts, and did not visualize the distal CBD. An anterior choledochotomy was made. The MIG was cut to a shorter length with a scalpel and then used during open surgery to guide the 3.2mm choledochoscope into the proximal and distal bile ducts. No stone was seen in the distal duct, simply a compressed duct from the overlying edematous inflamed pancreas. The proximal bile ducts were somewhat dilated, but without stones. A T-tube was placed to drain the CBD.
Ten days postoperatively antibiotics were stopped along with TPN. The patient was started on a diet. Temperature trend was toward improvement, and oral diet was tolerated. The T-tube was left to drain. Patient was hospitalized for thirty-one days. The edema of the pancreas slowly resolved, and follow up cholangiogram demonstrated flow into the duodenum. The T-tube was clamped for several weeks with no ill effects, and eventually removed. The patient required insulin coverage during hospitalization, but this resolved, and no pseudocyst developed in follow up. The patient recovered back to his usual health.