Correct answer
d Laparoscopic cholecystectomy with intraoperative cholangiogram (IOC)
This patient has mild gallstone pancreatitis. The next step should be determined by the likelihood of having common bile duct stones based on clinical risk factors. The Society of American Gastrointestinal and Endoscopic Surgeons published guidelines on the management of choledocholithiasis and it lists four risk factors for choledocholithiasis: common bile duct stone on abdominal ultrasound, dilated common bile duct (>8 mm), clinical evidence of acute cholangitis, total bilirubin >1.7 mg/dl. The presence of 2 or more factors indicate a high probability, no factors to be low probability, and one factor to be intermediate probability for choledocholithiasis.
Both SAGES and the American Society of Gastrointestinal Endoscopists (ASGE) have advocated limiting the use of ERCP to those with high risk for choledocholithiasis and those with signs of cholangitis.
In patients with intermediate probability, such as this patient, SAGES has two options for management: laparoscopic cholecystectomy with intraoperative cholangiogram (IOC) OR preoperative MRCP or endoscopic ultrasound. Recent reports in the pediatric surgical literature have favored laparoscopic IOC with common bile duct exploration (CBDE) over preoperative ERCP in intermediate risk patients. Recognizing that formal CBDE skills may be “rusty” in pediatric surgeons, Bosley et al published a recent report using “balloon sphincteroplasty” where dilating balloons are introduced through the cystic duct approach to stretch the sphincter of Oddi with subsequent ductal flushing is a relatively simple option of clearing the duct.
Single stage (laparoscopic cholecystectomy, intraoperative cholangiogram, CBDE) management of common duct stones is less expensive than two stages and exposes the patient to fewer anesthesia episodes.
Notably, ASGE recommends against urgent ERCP in patients with gallstone pancreatitis with no evidence of cholangitis or biliary obstruction.
