Mild Acute Gallstone Pancreatitis Research Articles

Outcome of Early Cholecystectomy in Mild Biliary Pancreatitis

Acute biliary pancreatitis (ABP) caused by gallstones and biliary sludge1 is the most important cause of Acute Pancreatitis (AP). Aim: Effect of early cholecystectomy in mild acute biliary pancreatitis. Methods: This was a hospital based observational study, by convenience sampling recruited 60 patients of mild acute biliary pancreatitis eligible as per inclusion criteria within study duration of one year reported at Department of Surgery, Sardar Patel Medical College, PBM Hospital, Bikaner. Results: mean age was 44.76±9.88 yr (range 30- 70), 60% were female, 51.67% had pain & nausea as chief complaint, 71.66% patients had Cholelithiasis on MRCP. 6.68% had 3 CT severity score preoperatively whereas 1.66% had 3 CT severity score postoperatively. 56.67% cases had surgery after 72-96 hr. Success rate of early cholecystectomy was 98.33%. 56.67% cases had surgery after 72-96 hr mean 101.6± 14.89 hr. Only one case had recurrence on 3 months follow up. Conclusion: Early Cholecystectomy for patients with acute mild gallstone pancreatitis was found to be a safe procedure when performed during the index admission. Keywords: Early Cholecystectomy; Biliary pancreatitis. Introduction Acute biliary pancreatitis (ABP) caused by gallstones and biliary sludge1 is the most important cause of Acute Pancreatitis (AP), accounting for up to 75% of cases.2 Although most cases of ABP are mild and Self-limiting, a small group (20%) of patients may develop severe pancreatitis, which is associated with high morbidity and mortality.3 Commonly, after resolution of the initial attack of APB, patients may experience a recurrent attack (40% to 60%) within 2 weeks or other gallstonerelated complications such as biliary colics, acute cholecystitis, acute cholangitis or common bile duct (CBD) obstruction. Acute pancreatitis is a common disease in the emergency room with an annual incidence rangin.

WE2.3 Comparative study of early versus delayed laparoscopic cholecystectomy following endoscopic sphincterotomy for mild to moderate acute biliary pancreatitis

Abstract Background Acute pancreatitis is an inflammatory disease of the pancreas with acute biliary pancreatitis (ABP) accounting for 75% of cases. Current recommendations favour early laparoscopic cholecystectomy (LC) for mild acute gall stone pancreatitis during the same index admission to prevent recurrent attacks reported to be as high as 18–61% in various studies. Endoscopic sphincterotomy in cases who are unfit for cholecystectomy during the index admission or there is delay in cholecystectomy due to logistics may benefit from ES while waiting for elective cholecystectomy, in terms of reducing the number of recurrent attacks and decreasing morbidity. Methods A total of fifty-seven (57) patients of mild to moderate ABP were included in this study and were divided into three groups undergoing LC within 5 days of admission, ES within 7 days of onset of pain abdomen and LC within 4 weeks of initial illness and LC after 8 weeks of attack in the three respective groups and evaluated for level of difficulty of cholecystectomy, recurrent attacks and associated morbidity. Results Difficult LC in terms of adhesions, calots anatomy was seen in 17(n=57) patients. 13(n=38) patients had recurrent attack of pancreatitis during the waiting period for cholecystectomy, 2(n=19) in the ER group and 11(n=19) in the conservative management group, with all patients in the conservative group having more than 2 recurrent attacks. Conclusion LC in early period is a safe, effective, in patients of gallstone induced pancreatitis. ES is well tolerated and viable alternative to cholecystectomy to prevent recurrent pancreatitis until definitive treatment.

Comparative Study between Early versus Delayed Laparoscopic Cholecystectomy in Mild Acute Gallstone Pancreatitis

Comparative Study between Early versus Delayed Laparoscopic Cholecystectomy in Mild Acute Gallstone Pancreatitis

Laparoscopic cholecystectomy for mild acute gallstone pancreatitis-indication itself is a good predictor of (minimal) intraoperative difficulty-a retrospective cohort study.

The literature predicting difficulties during Laparoscopic Cholecystectomy (LC) for Acute Gallstone Pancreatitis (AGP) is mainly focused on the timing of operation. In our experience, LC for AGP is rarely difficult irrespective of the timing of operation. The aim of this study was to assess intra- operative difficulties in mild AGP patients to verify this observation. A retrospective analysis of all consecutive patients who underwent LC for mild AGP between 2014 and 2018 in a single centre was performed. Patients with known alcohol abuse, post-endoscopic retrograde cholangiopancreaticography (ERCP) induced pancreatitis, and those with chronic pancreatitis were excluded. Univariate weighted analysis was performed with 11 factors, with a linear threshold boundary defined as the mean distance between the four degrees of difficulty (DoD 1-4). Ninety-six patients (Male= 33, median age= 56; Female= 63, median age= 52) were analysed. Majority of the patients were an ASA of two (n= 50; 52%) with a median BMI of 28 (range 18-50). Five procedures were technically difficult (DoD≥ 3) and only one procedure was converted to open operation. Univariate analysis showed that duration of pancreatitis >6 days (p= 0.002) and evidence of acute cholecystitis (p <0.05) are associated with a difficult LC (DoD≥ 3). The rest of the factors did not influence DoD. Based on this result, we suggest that LC for mild AGP is rarely difficult, and this finding can be used in practice for selecting these patients for training lists.

Laparoscopic cholecystectomy in acute mild gallstone pancreatitis: how early is safe?

Introduction: There is still controversies about which surgical strategy is most appropriate to resolve the underlying biliary pathology in patients with Acute Gallstone-Pancreatitis (AGP).The aim was to evaluate the safety and effectiveness of Early Laparoscopic Cholecystectomy (ELC)in patients with Mild-AGP.

Laparoscopic cholecystectomy in acute mild gallstone pancreatitis: how early is safe?

The surgical strategy to resolve the underlying biliary pathology in patients with acute gallstone pancreatitis (AGP) remains controversial. The aim of this study was to evaluate the safety and effectiveness of early laparoscopic cholecystectomy (ELC) in patients with mild AGP. A retrospective cohort of consecutive patients diagnosed with mild AGP according to the Atlanta Guidelines from January 2009 to July 2019 was selected. Patients were assigned to surgery on the first available surgical shift, 48h after the symptoms onset. Univariate analysis was performed to determine the association between AGP and grades of Balthazar (A, B and C) with time to surgery, days of hospitalization and postoperative complications. From 239 patients evaluated, 238 (99.58%) were operated by laparoscopic approach. Intraoperative cholangiogram was performed routinely. Choledocholithiasis, if present, was successfully treated by laparoscopic common bile duct exploration in all cases. A significant association was found between Balthazar grades and time to surgery (median of 3days, p = 0.003), with length hospitalization and from surgery to discharge, with median of 4days (p = 0.0001) and 2days (p = 0.003), respectively. Mild postoperative complications (CD I/II) were observed in 22/239 patients (9.2%). This represents 2% of patients with grade A of Balthazar, 9% of grade B and 14% of grade C (p = 0.016). We observed no severe complications or mortality. ELC with routine intraoperative cholangiogram, performed on the first available surgical shift 48h after the symptoms of pancreatitis onset, is a viable, effective and safe strategy for the resolution of mild AGP and its underlying biliary pathology in a single procedure.

The optimal timing of laparoscopic cholecystectomy in patients with mild gallstone pancreatitis: A meta-analysis.

Background:The optimal timing of laparoscopic cholecystectomy (LC) in patients with mild acute gallstone pancreatitis (MAGP) is controversial. The aim of this study was to systematically evaluate and compare the safety and efficacy of early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) in patients with MAGP.Methods:A strict search was conducted of the electronic databases, including PubMed, MEDLINE Embase, the ISI Web of Science, and Cochrane Library for all relevant English literature and RevMan5.3 software for statistical analysis was used.Results:A total of 19 studies comprising 2639 patients were included. There was no significant difference in intraoperative complications [risk ratio (RR) = 1.46; 95% confidence interval (CI) = 0.88–2.41; P = .14)], postoperative complications (RR = 0.81; 95% CI = 0.58–1.14; P = .23), rate of conversion to open cholecystectomy (RR = 1.00; 95% CI = 0.75–1.33; P = .99), operative time (MD = 1.60; 95% CI = −1.36–4.56; P = .29), and rate of readmission (RR = 0.63; 95% CI = 0.19–2.10; P = .45) between the ELC and DLC groups. However, the ELC group was significantly correlated with lower length of hospital stay (MD = −2.01; 95% CI = −3.15 to −0.87; P = .0006), fewer gallstone-related events rates (RR = 0.17; 95% CI = 0.07–0.44; P = .0003), and lower endoscopic retrograde cholangiopancreatography (ERCP) usage (RR = 0.83; 95% CI = 0.71–0.97; P = .02) compared with the DLC group.Conclusion:Early laparoscopic cholecystectomy is safe and effective for patients with MAGP, but the indications and contraindications must be strictly controlled.

Acute mild gallstone pancreatitis: timing of cholecystectomy

Background: Cholecystectomy is essential to prevent recurrent attacks of mild acute gallstone pancreatitis, but the precise timing of cholecystectomy remains a subject of ongoing debate. The aim of this study is to address the optimal timing of cholecystectomy in patients with mild acute gallstone pancreatitis.Methods: From September 2013 to September 2018, patients with mild acute gallstone pancreatitis were prospectively randomized to either an early laparoscopic cholecystectomy (ELC) versus a delayed laparoscopic cholecystectomy (DLC) group. Recurrent biliary complications, success and failure rate, difficulty of cholecystectomy, operative time, cholecystectomy related complications, length of admission between the two groups were evaluated.Results: A total of 80 patients were randomized to the ELC (41 patients) and to the DLC group (39 patients). There were a statistically significant differences in the total length of hospital stay and recurrent biliary events (4.5±1.1 vs. 7.4±2.6 days, p&lt;0.01 and 4.9% vs. 41%, p&lt;0.001; respectively). There were no differences regarding success and failure rate, difficulty of cholecystectomy, operative time, cholecystectomy related complications, and length of index admission between both groups.Conclusions: In mild gallstone pancreatitis, ELC results in a shorter overall hospital stay with a significant reduction in the recurrent biliary events with no apparent impact on the safety and technical difficulty of the procedure or perioperative complication rate.

Same Admission Cholecystectomy (SAC) Compared to Delayed Cholecystectomy (DC) in Patients with Mild Acute Gallstone Pancreatitis (GSP): Outcomes and Predictors in a Safety Net Hospital Cohort

Same Admission Cholecystectomy (SAC) Compared to Delayed Cholecystectomy (DC) in Patients with Mild Acute Gallstone Pancreatitis (GSP): Outcomes and Predictors in a Safety Net Hospital Cohort

Unrecognized necrosis at same admission cholecystectomy for pancreatitis increases organ failure and infected necrosis

Background and aimsGuidelines recommend same admission cholecystectomy (SAC) in the management of mild acute gallstone pancreatitis (AGP) with a recent randomized trial supporting this recommendation. However, the push for early cholecystectomy will lead a subset of patients with evolving, unrecognized necrotizing pancreatitis (NP) to undergo laparoscopic cholecystectomy (LC) with unknown consequences. With concerns about potentially serious outcomes, we studied the outcomes in patients with unrecognized NP who underwent SAC and identified predictors of unrecognized NP at the time of SAC. MethodsRetrospective study of patients who appeared to have mild AGP but subsequently discovered to have unrecognized NP after SAC (study group). Outcomes were compared to a similar cohort with necrotizing AGP who did not undergo SAC (control group 1). Predictors for unrecognized NP at the time of SAC were identified through logistic regression using a second control group with truly mild AGP undergoing SAC. ResultsPatients in the study group (N = 46) undergoing SAC demonstrated higher rates of persistent organ failure (p = 0.0003), infected necrosis (p = 0.02), and length of hospital stay (p = 0.049) compared to a similar group (N = 48) with necrotizing AGP who did not undergo SAC. Persistent SIRS (p < 0.0001) and WBC >12 × 109/L (p < 0.0001) on the day of cholecystectomy were associated with evolving/unrecognized NP. ConclusionsUnrecognized NP at the time of SAC is associated with increased rates of subsequent persistent organ failure, infected necrosis, and length of hospital stay. Persistent leukocytosis and SIRS at the time of proposed cholecystectomy are predictive of unrecognized NP and should prompt contrast enhanced CT prior to proceeding with LC.

The Value of Performing Early Non-enhanced CT in Developing Strategies for Treating Acute Gallstone Pancreatitis

BackgroundThe purpose of this study is to assess the value of early abdominal non-enhanced computed tomography (NECT) in developing strategies for treating acute gallstone pancreatitis (AGP). MethodsAGP patients underwent NECT within 48 h after symptom onset to determine the presence of peripancreatic fluid collection, gallstones, and common bile duct stones. Patients with mild AGP who had neither organ failure by clinical data nor peripancreatic fluid collection by NECT (classified as grade A, B, or C based on the Balthazar CT grading system) were randomized to undergo an early laparoscopic cholecystomy (ELC; LC performed within 7 days after a pancreatitis attack, without waiting for symptom resolution) or late laparoscopic cholecystomy (LLC; LC performed ≥ 7 days following an attack, with the patient being completely free of AGP symptoms). ResultsThe study enrolled 102 patients with mild AGP defined by clinical data and NECT. NECT was 89.2 % and 87.8 % accurate in detecting gallbladder stones and CBD stones, respectively. Totals of 49 and 53 patients were assigned to an ELC and LLC group, respectively. All patients in both groups were cured, no LC-related complications occurred, and no case of AGP increased in severity following LC. The mean lengths of hospital stay and LC operation time were significantly shorter in the ELC group than the LLC group (P < 0.05). ConclusionsNECT can accurately detect peripancreatic fluid collection and biliary obstructions; thus, early abdominal NECT is valuable when developing strategies for treating AGP. Patients with mild AGP without organ failure or peripancreatic fluid collection can safely undergo ELC without waiting for complete resolution of their pancreatitis.

Readmissions due to acute biliary edematous pancreatitis in patients without cholecystectomy.

Analyzing the readmission of patients with acute biliary edematous pancreatitis (ABEP) without cholecystectomy despite a previous episode of mild acute gallstone pancreatitis or lithiasic cholecystitis. Calculating the health costs associated with the non-performance of cholecystectomy. Prospective observational study conducted at a tertiary hospital from July to November 2014. The study has consecutively included inpatients suffering from ABEP who: a) had suffered a previous episode of mild acute gallstone pancreatitis or cholecystitis at least 2 weeks before readmission; and b) had not undergone cholecystectomy despite the lack of contraindications. During the research period, 9 patients (7 females and 2 males) with a mean age of 65.3 years (standard deviation [SD] 19.2) were readmitted. The median number of days between the previous episode of ABEP or cholecystitis and the readmission was 114 days (interquartile range [IQR] 111.0). Reported median overall length of hospital stay was 10 days (IQR = 2.0). Patients underwent a mean of 2.8 (SD = 1.2) ultrasound scans, 1.3 (SD = 0.9) abdominal and pelvic CT, 0.8 (SD = 1.0) MRCP and 0.2 (SD = 0.4) ERCP. The mean cost per patient for each readmission, including hospital stay (143.0 €/day), Emergency Service (332.31 €) and tests performed was 2,381.70 €/patient. Not performing a cholecystectomy within two weeks after a first episode of mild ABEP or cholecystitis contributes to patient readmission due to recurrent pancreatitis, resulting in avoidable treatment costs.

Management of acute mild gallstone pancreatitis under acute care surgery: should patients be admitted to the surgery or medicine service?

BackgroundWe hypothesized that patients with acute mild gallstone pancreatitis (GSP) admitted to surgery (SUR; vs medicine [MED]) had a shorter time to surgery, shorter hospital length of stay (HLOS), and lower costs. MethodsWe performed chart reviews of patients who underwent a cholecystectomy for acute mild GSP from October 1, 2009 to May 31, 2013. We excluded patients with moderate to severe and non-gallstone pancreatitis. We compared outcomes for time to surgery, HLOS, costs, and complications between the 2 groups. ResultsFifty acute mild GSP patients were admitted to MED and 52 to SUR. MED patients were older and had more comorbidity. SUR patients had a shorter time to surgery (44 vs 80 hours; P < .001), a shorter HLOS (3 vs 5 days; P < .001), and lower hospital costs ($11,492 ± 6,480 vs $16,183 ± 12,145; P = .03). In our subgroup analysis on patients with an American Society of Anesthesiologists score between 1 and 2, the subgroups were well matched; all outcomes still favored SUR patients. ConclusionsAdmitting acute mild GSP patients directly to SUR shortened the time to surgery, shortened HLOS, and lowered hospital costs.

Early versus interval cholecystectomy after mild acute gallstone pancreatitis: A 10 year experience in central Saudi Arabia

To study the safety of early cholecystectomy (EC) during the index admission following acute mild gallstone pancreatitis, focusing on conversion rate, biliary injuries, length of hospital stay and recurrent gallstone related events. Medical records of all patients who were admitted with a diagnosis of acute mild gallstone pancreatitis at King Saud Medical City, Riyadh, Kingdom of Saudi Arabia between January 2003 and December 2012 were studied retrospectively and reviewed in relation to age, gender, presenting symptoms, laboratory findings, imaging studies, timing of cholecystectomy, biliary injury, intraoperative bleeding, conversion to open surgery, duration of surgery, operating surgeons, hospital stay, recurrent gallstone related events and mortality. Out of 386 patients admitted with acute mild gallstone pancreatitis, 267 patients underwent EC which was successfully performed in 256 cases. Conversion to open cholecystectomy was needed in 11 cases. The rest of the patients ( n = 119) were discharged after successful conservative treatment for interval cholecystectomy (IC) after 6–12 weeks. IC was performed on 83 patients, two were converted to open cholecystectomy. Hospital stay was significantly shorter in the EC ( P < 0.0001) while the recurrent gallstone related events were significantly higher in IC ( P < 0.0001). There was no significant difference in conversion rate ( P = 0.567), and biliary complications ( P = 0.663). EC following acute mild gallstone pancreatitis was found to be a safe procedure when performed during the index admission. There was no significant increase in conversion rate or bile duct injuries. In fact, EC resulted in significant reduction in the hospital stay as well as in the recurrent gallstone related events.

Cost-effectiveness of early laparoscopic cholecystectomy for mild acute gallstone pancreatitis.

A recent Cochrane review suggested that laparoscopic cholecystectomy carried out early following mild gallstone pancreatitis was safe. This study compared the cost-effectiveness of laparoscopic cholecystectomy performed within 3 days of admission, during the same admission but after more than 3 days, or electively in a subsequent admission. A model-based cost-utility analysis was performed estimating mean costs and quality-adjusted life-years (QALYs) per patient in the UK National Health Service with a 1-year time horizon. A decision tree model was constructed and populated with probabilities, outcomes and cost data from published sources for mild gallstone pancreatitis, including one-way and probabilistic sensitivity analyses. The costs of laparoscopic cholecystectomy performed within 3 days of admission, beyond 3 days but in the same admission, and electively in a subsequent admission were € 2748, € 3543 and € 3752 respectively; the QALYs were 0.888, 0.888 and 0.884 respectively. Early laparoscopic cholecystectomy had a 91 per cent probability of being cost-effective at the maximum willingness to pay for a QALY commonly used in the UK. It is acknowledged that many hospitals do not have access to magnetic resonance cholangiopancreatography and endoscopic retrograde cholangiopancreatography, especially at weekends, and that implementing a 3-day target is unrealistic without allocating new resources that could erode the cost-effectiveness. Performing laparoscopic cholecystectomy for mild gallstone pancreatitis within 3 days of admission is cost-effective, but may not be feasible without significant resource allocation. After 3 days there is little financial advantage to same-admission operation.

Endoscopic Ultrasound Should Be Performed Before Endoscopic Retrograde Cholangiopancreatography in All Patients With Mild Acute Gallstone Pancreatitis

Endoscopic Ultrasound Should Be Performed Before Endoscopic Retrograde Cholangiopancreatography in All Patients With Mild Acute Gallstone Pancreatitis

MANAGEMENT OF ACUTE GALLSTONE PANCREATITIS: SO THE STORY CONTINUES

Surgical audit on management of mild acute gallstone pancreatitis at Western Health showed that non-compliance of carrying out laparoscopic cholecystectomy or endoscopic retrograde cholangiopancreatography and sphincterectomy within 4 weeks had resulted in a high readmission rate. Modification of management was then instituted and audit cycle repeated to assess the outcome. Medical records of patients with mild acute gallstone pancreatitis between January 2000 and February 2002 were audited. The pathology results and medical imaging suggestive of acute gallstone pancreatitis were analysed. Patients with less than three positive Ranson's criteria were included in the surgical audit. Information on the course of treatment, including method (laparoscopic cholecystectomy or endoscopic retrograde cholangiopancreatography and sphincterectomy), timing, reason of non-operation and outcome were recorded. Reasons for failing to remove stones in a timely fashion were identified and strategies to improve compliance with the guidelines were implemented. An audit was repeated 10 months later to assess changes in practice. The rate of carrying out timely stone removal has improved from 57 to 82% at the follow-up audit. The readmission rate has also significantly decreased. Nevertheless, the rate of carrying out laparoscopic cholecystectomy during the original admission for suitable candidates was still at 39%. Surgical audit has identified a need to improve in the management of mild acute gallstone pancreatitis in the Western Health system. By complying with guidelines, outcomes of patient care have improved.