Cholecystectomy For Gallstone Pancreatitis Research Articles

Recent Treatment Strategies for Acute Pancreatitis.

Acute pancreatitis (AP) is a leading gastrointestinal disease that causes hospitalization. Initial management in the first 72 h after the diagnosis of AP is pivotal, which can influence the clinical outcomes of the disease. Initial management, including assessment of disease severity, fluid resuscitation, pain control, nutritional support, antibiotic use, and endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis, plays a fundamental role in AP treatment. Recent updates for fluid resuscitation, including treatment goals, the type, rate, volume, and duration, have triggered a paradigm shift from aggressive hydration with normal saline to goal-directed and non-aggressive hydration with lactated Ringer's solution. Evidence of the clinical benefit of early enteral feeding is becoming definitive. The routine use of prophylactic antibiotics is generally limited, and the procalcitonin-based algorithm of antibiotic use has recently been investigated to distinguish between inflammation and infection in patients with AP. Although urgent ERCP (within 24 h) should be performed for patients with gallstone pancreatitis and cholangitis, urgent ERCP is not indicated in patients without cholangitis. The management approach for patients with local complications of AP, particularly those with infected necrotizing pancreatitis, is discussed in detail, including indications, timing, anatomical considerations, and selection of intervention methods. Furthermore, convalescent treatment, including cholecystectomy in gallstone pancreatitis, lipid-lowering medications in hypertriglyceridemia-induced AP, and alcohol intervention in alcoholic pancreatitis, is also important for improving the prognosis and preventing recurrence in patients with AP. This review focuses on recent updates on the initial and convalescent management strategies for AP.

Contemporary management of acute pancreatitis: What you need to know.

Acute pancreatitis and management of its complications is a common consult for the acute care surgeon. With the ongoing development of both operative and endoscopic treatment modalities, management recommendations continue to evolve. We describe the current diagnostic and treatment guidelines for acute pancreatitis through the lens of acute care surgery. Topics, including optimal nutrition, timing of cholecystectomy in gallstone pancreatitis, and the management of peripancreatic fluid collections, are discussed. Although the management severe acute pancreatitis can include advanced interventional modalities including endoscopic, percutaneous, and surgical debridement, the initial management of acute pancreatitis includes fluid resuscitation, early enteral nutrition, and close monitoring with consideration of cross-sectional imaging and antibiotics in the setting of suspected superimposed infection. Several scoring systems including the Revised Atlanta Criteria, the Bedside Index for Severity in Acute Pancreatitis score, and the American Association for the Surgery of Trauma grade have been devised to classify and predict the development of the severe acute pancreatitis. In biliary pancreatitis, cholecystectomy prior to discharge is recommended in mild disease and within 8 weeks of necrotizing pancreatitis, while early peripancreatic fluid collections should be managed without intervention. Underlying infection or ongoing symptoms warrant delayed intervention with technique selection dependent on local expertise, anatomic location of the fluid collection, and the specific clinical scenario. Landmark trials have shifted therapy from maximally invasive necrosectomy to more minimally invasive step-up approaches. The acute care surgeon should maintain a skill set that includes these minimally invasive techniques to successfully manage these patients. Overall, the management of acute pancreatitis for the acute care surgeon requires a strong understanding of both the clinical decisions and the options for intervention should this be necessary.

EGS P29 Evaluating Compliance and Identifying Barriers to Timely Cholecystectomy in Gallstone Pancreatitis: A Retrospective Study

Abstract Background Gallstone pancreatitis is a common cause of acute pancreatitis. Timely cholecystectomy within two weeks of admission is recommended by the UK Pancreatitis Guidelines and NCEPOD to prevent recurrent pancreatitis and associated complications. This study aimed to evaluate compliance with these guidelines at a District General Hospital. Methods A retrospective analysis was conducted on all patients (n=92) admitted with acute pancreatitis between July 1st 2022, and January 31st 2023. Patient demographics, diagnostic methods, time to surgery, and relevant laboratory values (median amylase, median CRP) were collected and analysed. Results 35% (n=32) of patients had gallstone pancreatitis. 26 were fit for cholecystectomy. 35% (n=9) were operated on within 2 weeks. Median time to surgery was 7 days and median CRP 133. There were no readmissions within 6 months. The delayed surgery cohort (n=17) had a median time to surgery of >60 days, median CRP 29 and a 59% (n=10) readmission rate . 1 patient had three readmissions. Reasons for delay were: 2 pancreatic necrosis, 1 pregnancy, 1 pneumonia, 1 delirium, 2 bed pressure, and 10 no clinical reason. 5 patients are still waiting for surgery at the time of analysis >6months. Conclusions Prior to the COVID-19 pandemic, compliance with UK pancreatitis and NCEPOD guideline was excellent (GIRFT) at our institution. Our findings are that most patients with gallstone pancreatitis are not being operated upon within two weeks. Delays result in hospital readmissions increasing resource use. Most delays were organisational rather than clinical. Patients who were ambulated for operative management within 2 weeks rarely were operated upon within this timeframe. Trust initiatives aimed at COVID-19 recovery prioritised early discharge and repurposed emergency ‘hot lists’ to reduce elective waiting lists. Interventions to increase emergency operating capacity are most likely to improve matters.

Predictors of poor outcomes after cholecystectomy in gallstone pancreatitis: NSQIP analysis of 30-day morbidity and mortality.

Contemporary nationwide outcomes of gallstone pancreatitis (GSP) managed by cholecystectomy at the index hospitalization are limited. This study aims to define the rate of 30-day morbidity and mortality and identify associated perioperative risk factors in patients undergoing cholecystectomy for GSP. Patients from the ACS-NSQIP database with GSP without pancreatic necrosis, who underwent cholecystectomy during the index hospitalization from 2017 to 2019 were selected. Factors associated with 30-day morbidity and mortality were analyzed. Of the 4021 patients identified, 1375 (34.5%) were male, 2891 (71.9%) were White, 3923 (97.6%) underwent laparoscopic surgery, and 52.4years (SD ± 18.9) was the mean age. There were 155 (3.8%) patients who developed morbidity and 15 (0.37%) who died within 30days of surgery. In bivariate regression analysis, both 30-day morbidity and mortality were associated with older age, elevated pre-operative BUN, hypertension, chronic obstructive pulmonary disease, congestive heart failure, acute kidney injury, and dyspnea. ASA of I or II and laparoscopic surgery were protective against 30-day morbidity and mortality. In multivariable regression analysis, factors independently associated with increased 30-day morbidity included preoperative SIRS/sepsis [OR: 1.68 (95% CI: 1.01-2.79), p = 0.048], and age [OR: 1.03 (95% CI: 1.01-1.04), p = 0.001]. Factors associated with increased 30-day mortality included tobacco use [OR: 8.62 (95% CI: 2.11-35.19), p = 0.003] and age [OR: 1.10 (95% CI: 1.04-1.17), p = 0.002]. Patients with GSP without pancreatic necrosis can undergo cholecystectomy during the index admission with very low risk of 30-day morbidity or mortality.

Impact of hospital characteristics on best-practice adherence for gallstone pancreatitis: a nationwide analysis.

Current guidelines recommend cholecystectomy during the index admission for gallstone pancreatitis, and a growing body of evidence indicates that patients benefit from cholecystectomy within the first 48h of admission. We examined the impact of hospital characteristics on adherence to these data-driven practices. We queried the National Inpatient Sample for patients admitted for gallstone pancreatitis between October 2015 and December 2018. Patients who underwent same-admission cholecystectomy were identified by procedure codes. Cholecystectomies within the first two days were classified as early cholecystectomies. Multivariable logistic regression was used to determine the association between hospital characteristics and adherence to these practices. Of 163,390 admissions for gallstone pancreatitis, only 90,790 (55.6%) underwent cholecystectomy before discharge. Mean time from admission to cholecystectomy was 2.9days; 27.0% of patients (44,005) underwent early cholecystectomy. Odds of same-admission cholecystectomy were highest in large hospitals (OR 1.21, 95% CI 1.13-1.28), urban teaching centers (OR 1.33, 95% CI 1.21-1.46), and the South (OR 1.70, 95% CI 1.57-1.83). Odds of early cholecystectomy did not vary with hospital size, urban-rural status, or teaching status but were highest in the West (OR 1.98, 95% CI 1.80-2.18). Best-practice adherence for cholecystectomy in gallstone pancreatitis remains low despite an abundance of evidence and clinical practice guidelines. Active interventions are needed to improve delivery of surgical care for this patient population. Implementation efforts should focus on small hospitals, rural areas, and health systems in the Northeast region.

459 Implication of Changes in Management of Acute Pancreatitis During COVID-19 Pandemic

Introductionwhen COVID-19 pandemic stroked the country, the Royal College of Surgeons recommended cholecystectomy for gall stone pancreatitis could be delayed up to 12 weeks during Covid-19 pandemic. This may have exposed patients to recurrent gall stone morbidity and serious complications.MethodPatients admitted with gall stone pancreatitis during Covid-19 period 12th March 2020 till 15th June 2020 to Western Sussex hospitals were analysed retrospectively for a period of 3 months post index submission. The endpoints were readmission rates and complication relating to gall stones.Results32 patients admitted with acute gall stone pancreatitis, age 24-92 years (median 69) and a median hospital stay of 4 days.4(12.5%) patients had cholecystectomy during index admission. 1 died of pancreatitis during index admission.Of the remaining 27 patients, 11 (40.7%) were readmitted with recurrent pancreatitis (6); biliary sepsis (2); obstructive jaundice (1); spontaneous splenic haemorrhage (1) (died); recurrent biliary colic (1). The median time to readmission was 40 days (6 -89).ConclusionsDelaying cholecystectomy for gallstone pancreatitis to 3 months is associated with significant readmission rates and serious complications. Cholecystectomy for gallstone pancreatitis should be categorised as 1B or 2 during Covid-19 period.

S0043 Real World Practices of Same-admission Cholecystectomy in Gallstone Pancreatitis

INTRODUCTION: Cholecystectomy performed during an admission for gallstone pancreatitis (GP) has been reported to reduce both length of stay (LOS) and future encounters without causing an increase in complications. Despite this, rates of cholecystectomy remain low. To understand real-world trends of patients who underwent cholecystectomy after diagnosis of GP, we characterized their rates, risks, benefits, comorbid conditions, location of care and contrasted them across a nine-hospital system. METHODS: ICD-10 codes were used to retrieve charts of patients presenting to the MedStar Health between March 2015 and June 2019. These included emergency department visits and inpatient admissions. Charts meeting Revised Atlanta Classification for acute pancreatitis (AP) were reviewed. Charts that carried a diagnosis of GP were put into two groups, 1) those that underwent same-admission cholecystectomy (SAC) and 2) those who did not. These groups were then compared for the following variables: LOS, future encounter and complication rates, location of care, history of cholelithiasis or choledocholithiasis and presence of hypertension, coronary artery disease, congestive heart failure, asthma/chronic obstructive pulmonary disease, smoking status, chronic kidney disease or cirrhosis. Statistical analysis was performed using GraphPad PRISM. RESULTS: 1722 of 2541 charts met criteria for AP; 366 of which carried a diagnosis of GP. LOS was observed to be greater in those who underwent SAC when compared to those who did not (5.5 vs 4.2 days, 95% Cl 0.26–2.26, P = 0.0138.) Patients at tertiary centers were observed to have been less likely to undergo SAC (31.4% vs 44.5%, OR 0.570, P = 0.0151.) There was no significant difference in rates of future encounters or complications, presence of comorbidities or history of either cholelithiasis (50.0% vs 48.4%, P = 0.831) or choledocholithiasis (7.64% vs 8.60%, P = 0.847) between the two groups. CONCLUSION: In patients with GP, SAC was associated with increased LOS. Despite the association between choledocholithiasis or cholelithiasis and GP, there was no correlation between SAC and history of these prior conditions. This lower rate of SAC at tertiary centers could reflect a lack of penetrance of guideline adherence. Given these findings, the balance between benefit and risk remains to be one that warrants careful consideration and further investigation.Figure 1.: Length of stay compared between same-admission cholecystectomy and no cholecystectomy groupsFigure 2.: Prevalence of cholelithiasis history in same-admission cholecystectomy and no cholecystectomy groups.Figure 3.: Prevalence of choledocholithiasis history in same-admission cholecystectomy and no cholecystectomy groups.

The Role of Laparoscopic Cholecystectomy After Severe and/or Necrotic Pancreatitis in the Setting of Modern Minimally Invasive Management of Pancreatic Necrosis.

The trend toward minimally invasive procedures (MIP) in necrotizing pancreatitis is increasing. The optimal timing and technique of cholecystectomy in severe/necrotizing pancreatitis is unclear. This study aims to determine the role of laparoscopic cholecystectomy after severe/necrotizing pancreatitis in the context of MIP. Retrospective analysis of a prospective database was performed for consecutive patients after cholecystectomy for gallstone pancreatitis between January 2011 and January 2018 at Monash Health, Melbourne, Australia. Three hundred fifty-five patients with gallstone pancreatitis underwent laparoscopic cholecystectomy with 2 conversions. Patients with severe pancreatitis were older (P = 0.002), with a more even sex distribution when compared with mild pancreatitis. Females predominated in the mild pancreatitis group.Patients with moderate/severe pancreatitis (P = 0.002) and necrosis (P > 0.001) were more likely to have delayed cholecystectomy compared with mild pancreatitis. There was no increase in biliary presentations while awaiting cholecystectomy. Length of stay for patients with severe/necrotizing pancreatitis (P = 0.001) was increased, surgical complications appeared similar. Laparoscopic cholecystectomy can be performed safely and effectively for pancreatitis, irrespective of severity. The paradigm shift in the management of severe necrotizing pancreatitis away from open necrosectomy toward MIP can be extended to encompass laparoscopic cholecystectomy.

Can abdominal surgical emergencies be treated in an ambulatory setting?

The performance of emergency abdominal surgery in an outpatient setting is increasingly the order of the day in France. This review evaluates the feasibility and reliability of ambulatory surgical treatment of the most common abdominal emergencies: appendectomy for acute appendicitis and cholecystectomy for acute complications of gallstone disease (acute cholecystitis and gallstone pancreatitis). This study evaluates surgical procedures performed on an ambulatory basis according to the international definition (admission in the morning, discharge in the evening with a hospital stay of less than 12 hours). Just as for elective surgery, eligibility of patients for an ambulatory approach depends on the capacities of the surgical and anesthesia team: to manage the risks, particularly the risk of deferring surgery until the morning); to prevent or treat post-operative symptoms like pain, nausea, vomiting, re-ambulation in order to permit rapid post-operative discharge. Recent studies have shown that appendectomy for non-complicated acute appendicitis can be deferred for up to 12 hours without any increase in danger. Many other studies have shown that early discharge after appendectomy for acute non-complicated appendicitis is feasible and safe. Nonetheless, there is only one published series of truly ambulatory appendectomies. The results were excellent. Patients who presented in the afternoon were brought back for operation the following morning. The appropriate timing for performance of cholecystectomy in patients with acute calculous cholecystitis or gallstone pancreatitis has not been well defined, but is always somewhat delayed relative to the onset of symptoms. To minimize operative complications, cholecystectomy for acute calculous cholecystitis should probably be performed between 24 and 72 hours after diagnosis. Cholecystectomy for gallstone pancreatitis should probably not be delayed longer than a week; the need to keep the patient hospitalized during the interval has not been demonstrated. Early discharge after cholecystectomy was usually possible, even in series where acute cholecystitis was diagnosed intra-operatively. Cholecystectomy for acute cholecystitis and gallstone pancreatitis seems to be feasible but no reports specifically support this approach. Emergency abdominal surgery seems to be feasible on an ambulatory setting for non-complicated acute appendicitis, acute calculous cholecystitis and gallstone pancreatitis. Only a single French series on ambulatory appendectomy for acute appendicitis has been reported.

The Impact of Intraoperative Cholangiography on Recurrent Pancreatitis and Biliary Complications in Patients with Gallstone Pancreatitis

IntroductionAlthough gallstone pancreatitis is initiated by the presence of stones in the common bile duct, the benefit associated with routine intraoperative cholangiography at the time of cholecystectomy in these patients is unclear. The purpose of this study, using population-based data, was to determine the impact of cholangiography on clinical outcomes after cholecystectomy for gallstone pancreatitis. MethodsAll patients who were admitted to hospital from January 1, 1997 to December 31, 2001 in Nova Scotia, Canada with pancreatitis who underwent cholecystectomy during the same admission were identified. The rates of recurrent pancreatitis and biliary complications after surgery were compared between patients who underwent cholecystectomy with intraoperative cholangiography ± common bile duct exploration and those who underwent cholecystectomy alone, using three linked administrative databases. ResultsThree hundred thirty-two patients were identified, 119 had cholangiography at the time of cholecystectomy and 213 did not. After a median follow-up of after 3.8 years, there was no difference in the rate of recurrent pancreatitis or biliary complications between those who had cholangiography ± common bile duct exploration at the time of surgery and those who did not; 13.4 versus 10.8 %, respectively (p = 0.55). ConclusionsThese data suggest that intraoperative cholangiography does not improve outcomes after cholecystectomy for gallstone pancreatitis.

Early Cholecystectomy for Mild to Moderate Gallstone Pancreatitis Shortens Hospital Stay

The timing of cholecystectomy in gallstone pancreatitis remains controversial. We hypothesized that in patients with mild to moderate gallstone pancreatitis (three or fewer Ranson's criteria), performing early cholecystectomy before resolution of laboratory or physical examination abnormalities would result in shorter hospitalization, without adversely affecting outcomes. An observational study consisting of a retrospective and a prospective group was conducted. For the prospective group, a deliberate policy of early cholecystectomy (less than 48 hours from admission) was used. The primary end point was total length of hospital stay. Secondary endpoints were time from admission to definitive operation, need for endoscopic retrograde cholangiography, and major complications (organ failure and death). Group I consisted of 177 patients retrospectively reviewed, and Group II was composed of 43 patients prospectively followed. There were no differences between the two groups with respect to demographics. With respect to admission laboratory values, there was a significant difference in median serum amylase, but there were no differences in median serum levels of lipase, total bilirubin, albumin, white blood cell count, or Ranson's score. The median length of hospital stay was 7 days in Group I versus 4 days in Group II (p=or< 0.001). Median time from admission to cholecystectomy was 5 days in Group I versus 2 days in Group II (p=or< 0.0001). Complication rates were similar and there were no deaths in either group. In patients with mild to moderate gallstone pancreatitis, a policy of early cholecystectomy resulted in a significantly reduced length of hospital stay with no increase in complications or mortality.

Magnetic Resonance Cholangiography in Gallstone Pancreatitis

At our institutionwe have performed MRC as a routinebefore doing a cholecystectomy for gall-stone pancreatitis, relying on this tool tothe detriment of intraoperative cholan-giography (IOC). We have now rein-stated IOC due to some retained stonesthat have caused recurrent pancreatitis andduct obstruction in some of our patients.In this context, we wish to discuss somepoints in the Patients and Methods andResults sections of the paper. First, wewould like to question the authors aboutthe reason for lowering the threshold ofthe serum amylase diagnostic criterion totwice the upper limits of normal instead of3 times. Dr. Makary et al carried out anultrasonography only in 46 of the 64 pa-tients. How do they do the prospectivediagnosis of gallstone in acute pancreatitispatients?If one of the aims of the study wasto evaluate the accuracy of MRC in de-tecting CBD stones, it is not very accurateto rely on clinical course to exclude thepresence of CBD stone. They do so in 22patients, and admit the possibility of spon-taneous passing of calculi in one of theirpatients. Thus, are there some false nega-tive MRC not detected by undone directcholangiography to establish the accuracyof the test?If the potential role of routine MRCin the initial evaluation of these patients isto select patients that will benefit from apreoperative ERCP because of the pres-ence of CBD stones, why do they performpreoperative ERCP in 34 patients if only17 have positive MRC for calculi?We agree with the recommendationof performing MRC as initial diagnosticstudy in acute gallstone pancreatitis. Ifcholedocholithiasis is not present thena laparoscopic cholecystectomy withoutIOC can be approached. If they are, thenERCP can be undertaken previously lapa-roscopic cholecystectomy to deal withCBD stones. But a concern with the inter-val time between MRC and surgery mustbe raised. If the surgical procedure is notcompleted the same day as the MRC,then based on our own experiencethere is a lack of confidence in thediagnosis of an absence of stones.Three of our patients with prior lapa-roscopic cholecystectomy for symp-tomatic gallbladder disease, both withpreoperative MRC negative for CBDstones, have subsequently sufferedfrom symptomatic choledocholithia-sis. In 1 patient who had multicholeli-thiasis at the preoperative ultrasound,no stone was retrieved from the gall-bladder when the surgical procedurewas finished, suggesting the passage toCBD. For that reason we wish to warnabout the importance of time elapsebetween the MRC and surgical proce-dure. Curiously, such time elapse isnot specified in the article by Dr.Makary et al or in other studies aboutthe matter.

Pancreatic panniculitis

Background: Pancreatic panniculitis is a rare disease in which necrosis of fat in the panniculus and other distant foci occurs in the setting of pancreatic disease. Objective: Our purpose was to study the clinical and histopathologic features of this disease. Methods: We conducted a retrospective review of 11 patients. Results: In five patients subcutaneous fat necrosis preceded the diagnosis of pancreatic disease by an average of 13 weeks. Five of our patients had underlying pancreatitis, and the remainder had carcinoma of the pancreas. Joint manifestations were prominent in six patients. Intestinal submucosal fat necrosis developed in two cases and caused massive gastrointestinal bleeding in one. Acute lesions demonstrated focal fat necrosis with “ghost cells,” pathognomonic of this condition. Chronic lesions showed granulomatous and lipophagic panniculitis, with rare areas of basophilic fat necrosis. Cholecystectomy for gallstone pancreatitis was curative in two patients. Conclusion: Pancreatic panniculitis has distinctive clinical and pathognomonic histopathologic findings that can be the presenting features of pancreatic disease.