45 year old female with acute Cholelithiasis and biliary colic. Presented to ED. No history of liver problems or pancreatitis.
Nuclear Medicine Gallbladder scan showed: the gallbladder is not identified which may represent mechanical or functional cystic duct obstruction, and suggests cholecystitis in the proper clinical setting.
US showed GB distended; stones in GB. LFTs normal. 3 mm CBD.
No intra-op cholangiogram. No post-op studies before discharge.
Patient returned two weeks later with Acute Pancreattitis. CBC result: WBC: 11.9; Chemistry results: Glucose: 150; Total Bilirubin: 5.7; AST: 880; ALT: 1184; Total Alkaline Phosphatase: 261; and, Lipase: 137760 (extremely high). Urinalysis results: Protein: 30; Bilirubin: Small; Urobilinogen: 2.0; Bacteria: Few; and, Mucous: Rare.
MRCP without contrast:: No choledocholithiasis seen; no biliary dilation, small amount of fluid in the gallbladder, scattered intra-abdominal free fluid and residual inflammation of the pancreas.
repeat MRCP without contrast, severe pancreatitis, with diffuse pancreatic edema; extensive non-localized inflammatory fluid in the retroperitoneum and abdomen; and no pseudocyst.
Nuclear Medicine hepato with gallbladder scan: no focal intense uptake is seen to give convincing evidence of a leak; uptake remains in the liver 110 minutes after administration, without transit into the duodenum, which may represent marked bile stasis versus biliary duct obstruction.
Patient went on the develop necrotizing pancreatitis and is now disabled due to repeated and multiple admissions for pancreatic flare ups.
Question, is it likely the cause of the pancreatitis was due to a retained stone in the CBD? Should the surgeon have done an intraoperative cholangiogram to make sure no stones were left behind? Should a post op MRCP have been done to r/o residual stones.
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Do you believe there might have been medical error?
The US before the operation showed a normal caliber CBD without stones. In addition the LFTs were normal before the operation. Therefore no cholangiogram was indicated. The cholangio is done in these cases to r/o any bile duct injuries and not to detect stones as the pretest probability that this pt had CBD stones was zero. No malpractice here. No role for any other tests before or after the surgery. I suspect that a stone might have passed to the CBD during the manipulation of the cystic duct. Very unusual, but possible. No way to prevent it.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
Since there was no medical error, there is no causation. More likely than not the pancreatitis was not the result of any medical negligence. The MRCP showed no CBD dilatation or stones so I assume that the stone passed from the CBD to the duodenum, after causing pancreatitis. This is probably why GI didn't do a sphincterotomy with ERCP. The nuclear magnetic scan results make no sense, but should prompt to investigate the cause of pancreatitis with ERCP. Also if there is CBD obstruction without a stone that would rule out any wrong doing by the surgeon.
What makes you a good expert for this case?
This is one of my areas of expertise.
How often do you encounter cases similar to this one in your practice?
Every week.
Do you believe there might have been medical error?
The patient presented with clear indications for surgery. Standard of care in this particular case did not require any additional tests. Postoperative course was in no way related to any below standard of care by the surgeon. Postop maybe the patient passed a stone or there's another cause of the pancreatitis. More likely than not even intraoperative cholangiogram would have not identified any abnormalities and there was no indication to work up the biliary tree at the time of initial surgery
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
This is one of those cases where no matter what the surgeon does there is always the possibility of a bad outcome There was a clear indication for surgery, No indication to work up the biliary tree, And the problem happened two weeks later which makes me think there was either a stone that passed or another cause of pancreatitis
What makes you a good expert for this case?
Over 25 years of performing surgery, Continue to teach training educate both medical students and residents The ability to explain complex medical issues in a simple understanding manner to the court, attorneys, and the jury.
How often do you encounter cases similar to this one in your practice?
very common. . Gallbladder issues are very common whether it be problems with the biliary tree or pancreatitis.This is one of the more common scenarios that we see on daily basis In our academic institution at the VA medical center
Do you believe there might have been medical error?
Routine versus selective cholangiography has been a debate in surgery for almost 2 decades. Most surgeons practice selective intraoperative cholangiography (a smaller subset of surgeons perform cholangiography on all cases). The literature is full of debate on this but there is clear literature for indications for a selective cholangiography. In the end a cholangiogram should be considered for patients with an elevated bilirubin or a dilated CBD. In this case the patient had normal LFTs and a 3 mm CBD which is normal sized for a 45 year old. So the literature supports no cholangiogram for this patient. So the surgeons care was appropriate. The patient presented with acute cholecystitis (HIDA scan confirmed this) and the patient was offered a laparoscopic cholecystectomy. It appears the cholecystectomy was performed without complication and as noted a cholangiogram was not performed which as I mentioned above is appropriate for this patient.
Do you believe there might have been causation (i.e. the medical error resulted in an injury)?
I do not believe not performing a cholangiogram in a patient who had no indication for a cholangiogram (normal bilirubin and normal sized CBD) is an error. If no error then no causation. Of note- clearly even with a normal total bilirubin and normal sized CBD one can pass or have a retained gallstone in ones CBD. This happens in probably < 2% of patients and usually presents with jaundice and epigastric pain and requires an ERCP in the postop setting. However- in this case unfortunately the patient's CBD stone or stones led to severe pancreatitis.
What makes you a good expert for this case?
I am currently an Assistant Professor of Surgery at a major medical school and serve in our department as the Chief of General Surgery as well as the Vice Chairman of Patient Safety and Quality. I have one of the busiest general surgery practices in Queens NY (a borough of NY city with > 2 million people) and perform a large number of cholecystectomies both electively and as an emergency (when I take call). My division/department that I oversee has 6 elective general surgeons and 6 emergency surgeons and we perform > 800 cholecystectomies a year or >15 a week. None of these 12 surgeons perform routine cholangiography. We perform cholangiography for mild bilirubin elevations or mildly dilated ducts with normal LFTs (if the bilirubin is > 3 or the CBD is quite dilated most get a preop MRCP and a GI consult in case the MRCP shows a CBD stone). Despite this we have had patients with retained CBD stones requiring a postop ERCP and the consensus across the department if the LFTs prior to surgery were normal and the CBD is not dilated - despite the postop complication of a retained stone requiring an ERCP the care was appropriate. Back to the case presented if a very busy department of surgery with 12 surgeons and > 800 surgeries a year practices selective cholangiography clearly the surgeon in this case cannot be accused of deviation from the standard of care. I would say he or she handled this case appropriately.
How often do you encounter cases similar to this one in your practice?
As the chief of quality for the department I review all complications. About 3 years ago we had a similair case. An uneventful laparoscopic cholecystectomy with preop normal LFTs and CBD size (so no cholangioram was performed) who was discharged home and readmitted with severe pancreatitis requiring admission to the Surgical ICU and a period of intubation for respiratory failure. The patient eventually recovered and was discharged home.
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