Discussion.
Laparoscopic cholecystectomy (LC) is a widely utilized surgical
procedure across the globe, experiencing a significant rise in
prevalence over the past decade11. Research indicates
that approximately 60% of these procedures are performed in women, with
a mean age of 40 years and a standard deviation of plus or minus 10
years12. Notably, among patients diagnosed with
cholelithiasis aged 18 to 49, about 90% undergo LC13.
While this procedure is generally safe, it is important to acknowledge
the potential for complications. The most frequently reported
complications associated with LC include bile duct injury, bile leaks,
bleeding, and bowel injury. Postoperative acute pancreatitis (AP) may
occur due to retained stones or other surgical complications, with an
estimated incidence between 0.1% and 0.34% 14.Furthermore, a study conducted in Spain indicated that 6% of all
readmissions within 90 days following cholecystectomy were associated
with acute pancreatitis15.
Acute postoperative pancreatitis is a rare complication that can arise
following laparoscopic cholecystectomy. In most cases, this condition is
effectively managed with conservative treatment without any surgical
intervention, except for an active obstruction at the lower common bile
duct. During the early postoperative period, acute pancreatitis may be
attributed to the passage of a missed gallstone or biliary sludge
through the ampulla of Vater. Notably, even biliary microliths can
precipitate severe pancreatitis. These microliths have the potential to
pass through the common bile duct and traverse the Sphincter of Oddi,
resulting in a transient obstruction that typically resolves
spontaneously. This occurrence is often associated with
hyperbilirubinemia, which is generally obstructive. Historical studies
have highlighted that small gallstones, which may not be detected by
conventional cholecystographic techniques, are implicated in up to 75%
of idiopathic pancreatitis cases16.
Acute pancreatitis (AP) can arise from various causes, including
alcoholism, certain medications, cystic fibrosis, hypercalcemia,
hypertriglyceridemia, and trauma. After excluding these, patients who
have recently undergone cholecystectomy should be considered a relevant
risk factor. Acute cholecystitis can lead to complications, including
conversion to open surgery. Gallstone pancreatitis, although relatively
rare, is a notable risk associated with laparoscopic cholecystectomy
(LC), particularly as the likelihood of gallstones entering the biliary
tract increases with the number of stones. The tortuous anatomy of the
cystic duct can facilitate this passage. While laparoscopic procedures
typically have lower complication rates, they may increase the risk of
postoperative pancreatitis, especially due to potential bile duct
injuries during surgery. Additionally, anatomical variations, such as a
low-lying cystic duct or reduced bile duct diameter, and a history of
pancreatitis or cholangitis can further heighten the risk.
Post-cholecystectomy endoclip migration is also recognized as a
contributing factor to post-LC acute pancreatitis17.
Very few cases have been documented in the literature in this
contention. In this case report, a 23-year-old female patient with no
significant medical history was admitted to the emergency department
with complaints raising the suspicion of Iatrogenic AP secondary to a
recent laparoscopic cholecystectomy, which had been performed due to
chronic cholecystitis associated with cholelithiasis.
Although AP under such conditions is treated conservatively, yet its
diagnosis and early management is crucial for better outcome and
prevention of its relapse. In a clinical picture of epigastric pain
migrating to the back with nausea and vomiting of no explained cause,
It is imperative to perform an abdominal ultrasound showing the inflamed
pancreatic parenchyma within the first 48 hours of suspecting the
condition. Increased levels of serum Lipase (Normal <90mg/dl)
and Amylase (Normal <90mg/dl) should be considered to increase
diagnostic accuracy by up to 20%18. Another more
specific indicator for pancreatic inflammation is raised Serum
Trypsinogen level used in assessing the severity of the
condition19. In cases where biliary aetiology is still
suspected, more advanced diagnostic procedures such as MRCP or EUS
should be employed.
To assess the severity of pancreatitis, we utilize Ranson scoring, a
system that predicts the severity and mortality of acute pancreatitis
through 11 parameters evaluated at admission and 48 hours
later20. In this case Subsequent laboratory
investigations revealed a notable elevation in serum amylase and lipase
levels, with the total leukocyte count (TLC) recorded at
16400/microliter. The patient received a Ranson score of 2 at admission,
putting her in a low-risk category. Significantly, the patient’s
condition stabilized within 48 hours with a Ranson score of 0.
Another diagnostic criterion widely used nationally and internationally
is two out of three criteria comprising Epigastric pain radiating
towards the back, Elevated levels of serum Lipase and amylase (three
times above normal ), and Pancreatic And radiographic evidence showing
pancreatic parenchymal inflammatory signs23..
Following diagnosis, the management protocol includes fluid
resuscitation (FR), pain control, and nutritional support. The patients
should initially remain NPO21 with a nasogastric tube,
and receive antispasmodics, painkillers, and anti-emetics like
diphenhydramine HCL or ondansetron, with opioids being particularly
effective. Epidural analgesia is also a good option for pain management
and also associated with reduced mortality22. Studies
suggest Ringer lactate’s effectiveness over normal saline in acute
pancreatitis, but the fluid rate is more crucial than the type used. For
hypovolemic patients, fluid boluses yield better outcomes. Nutritional
support within 24 to 48 hours, is important in reducing bacterial
translocation, decreasing infection risk, and supporting gut microbiota.
IV fluids should be stopped once the patient can tolerate oral intake.
Current guidelines advise against prophylactic antibiotics in predicted
severe AP or sterile necrosis due to the risk of multidrug-resistant
bacteria and fungal super infection24.. However, in
severe cases of AP with no progression towards betterment, antibiotic
regimens are also started25.
In this case, Following a Ranson score of 2, the patient was placed NPO
and started on Toradol and Provas for pain management. Fluid
resuscitation was provided with 5% Dextrose saline. Intravenous
Meropenem 1g was administered three times daily for antibiotic coverage,
as studies suggest Carbapenems can reduce the risk of infection in acute
pancreatitis and related conditions26.