Gallstone pancreatitis management: Are we following the guidelines?

Abstract

Background: Advances in the management of biliary pancreatitis were summarized in major international guidelines. Speedy diagnosis and stabilization, followed by definitive treatment during the index admission have been shown to reduce complications and cost. Objectives: To determine the compliance of a tertiary care center in Saudi Arabia with published guidelines on gallstone management of patients with acute gallstone pancreatitis. Settings: King Fahad Medical City, Riyadh, Saudi Arabia. Patients and Methods: Seventy-five consecutive patients presenting with gallstone pancreatitis from January 2010 to January 2012 were audited retrospectively. We assessed the definitive diagnosis method, the Ranson's severity score on admission, method of common bile duct (CBD) clearance, and the definitive treatment (cholecystectomy), if was done during index admission. We used practice guidelines of the American College of Gastroenterology and JPN guidelines for gallstone pancreatitis as reference. Complications of treatment and readmissions, as well as the length of stay, were also recorded. Results: A total of 68 patients fulfilled our criteria. Etiology was confirmed in all patients within 48 h. Overall, 24 (35%) patients underwent endoscopic retrograde cholangiopancreatography. Magnetic resonance cholangiopancreatography was done in 10 (15%) patients and 4 (6%) had both. Intraoperative cholangiogram was done in 5 (7%) patients, giving a definitive CBD clearance in 35 patients (51%). Twenty-seven (40%) patients had index admission cholecystectomy, whereas 41 (60%) were discharged for interval cholecystectomy. Among the delayed group, 10 (24%) were readmitted with recurrent pancreatitis while awaiting surgery, whereas 2 (7.4%) patients in the early surgery group were readmitted with obstructive jaundice ( P = 0.016). Conversion to open cholecystectomy occurred in 4 patients (10%) in the delayed surgery group and none in the index admission surgery group ( P = 0.098). Overall complication rates were 19% in the delayed surgery group and 11% in the index admission surgery group ( P = 0.16) Median length of hospital stay was 12.5 days and 9.5 days, respectively ( P = 0.028). Conclusion: The management of gallstone pancreatitis could be improved with greater adherence to international published guidelines in terms of timing of definitive treatment and method of CBD clearance, which in turn may result in a reduction of the rate of complications and length of overall hospital stay.