Management Of Gallstone Pancreatitis Research Articles

984 ERCP and Sphincterotomy (ES): A Safe and Effective Definitive Management of Gallstone Pancreatitis With the Gallbladder Left in Situ?

984 ERCP and Sphincterotomy (ES): A Safe and Effective Definitive Management of Gallstone Pancreatitis With the Gallbladder Left in Situ?

Effect of Medical or Surgical Admission on Outcome of Patients with Gallstone Pancreatitis and Common Bile Duct Stones

IntroductionManagement of uncomplicated common bile duct stone (CBDS) and gallstone pancreatitis (GP) presumably varies based on whether a patient is admitted to medicine or surgery. This study evaluates the impact of admitting team on outcome and cost. MethodsThree hundred seventy patients admitted to the Massachusetts General Hospital for CBDS or GP were retrospectively analyzed for demographics, insurance status, procedures, complications, length of stay, readmission, and cost. A multivariable analysis was conducted for outcome and cost measures. ResultsPatients admitted to a surgical service were younger than those admitted to a medical service. Gender, race, tobacco use, and the presence of chronic obstructive pulmonary disease and chronic renal insufficiency were not significantly different between groups. Patients admitted to a medical service had a higher incidence of coronary artery disease and diabetes. Despite lower readmission rates for surgical patients, there was no difference in total hospital days between groups. Though total cost of an initial surgical admission was greater than a medical admission, total cost attributable to the index admission diminished over time and ultimately was not significant in follow-up. ConclusionsDespite variations in uncomplicated management of CBDS and GP, there is no difference, in long-term follow-up, in the total number of hospital days or cost for the management of CBDS or GP based on admitting team practices.

Endoscopic sphincterotomy and interval cholecystectomy are reasonable alternatives to index cholecystectomy in severe acute gallstone pancreatitis (GSP)

UK guidelines for gallstone pancreatitis (GSP) advocate definitive treatment during the index admission, or within 2 weeks of discharge. However, this target may not always be achievable. This study reviewed current management of GSP in a university hospital and evaluated the risk associated with interval cholecystectomy. All patients that presented with GSP over a 4-year period (2002-2005) were stratified for disease severity (APACHE II). Patient demographics, time to definitive therapy [index cholecystectomy; endoscopic sphincterotomy (ES); Interval cholecystectomy], and readmission rates were analysed retrospectively. 100 patients admitted with GSP. Disease severity was mild in 54 patients and severe in 46 patients. Twenty-two patients unsuitable for surgery underwent ES as definitive treatment with no readmissions. Seventy-eight patients underwent cholecystectomy, of which 40 (58%) had an index cholecystectomy, and 38 (42%) an interval cholecystectomy. Only 10 patients with severe GSP had an index cholecystectomy, whilst 30 were readmitted for Interval cholecystectomy (p = 0.04). The median APACHE score was 4 [standard deviation (SD) 3.8] for index cholecystectomy and 8 (SD 2.6) for Interval cholecystectomy (p < 0.05). Median time (range) to surgery was 7.5 (2-30) days for index cholecystectomy and 63 (13-210) days for Interval cholecystectomy. Fifty percent (19/38) of patients with GSP had ES prior to discharge for interval cholecystectomy. Two (5%) patients were readmitted: with acute cholecystitis (n = 1) and acute pancreatitis (n = 1) , whilst awaiting interval cholecystectomy. No mortality was noted in the Index or Interval group. This study demonstrates that overall 62% (22 endoscopic sphincterotomy and 40 index cholecystectomy) of patients with GSP have definitive therapy during the Index admission. However, surgery was deferred in the majority (n = 30) of patients with severe GSP, and 19/30 underwent ES prior to discharge. ES and interval cholecystectomy in severe GSP is associated with minimal morbidity and readmission rates, and is considered a reasonable alternative to an index cholecystectomy in patients with severe GSP.

JPN Guidelines for the management of acute pancreatitis: cutting-edge information

The JPN Guidelines for the Management of Acute Pancreatitis are organized under the subject headings: epidemiology, diagnosis, management strategy, severity assessment and transfer criteria, management of gallstone pancreatitis, nonsurgical management, and surgical management. The Guidelines contain cutting-edge information on each of these subjects, as well as a section on the Japanese medical insurance system which provides information that should prove useful to physicians in other countries. The quality of the evidence was evaluated by the evidence-based classification method used at the Cochrane Library. The levels of recommendation of the individual management methods contained in the Guidelines were determined on the basis of the evaluation of evidence by the consensus of the members of the Working Group (see below). The Japanese Society for Abdominal Emergency Medicine, the Japan Pancreas Society, and the Research Group for Intractable Diseases and Refractory Pancreatic Diseases (which is sponsored by the Japanese Ministry of Health, Labour, and Welfare) were commissioned to produce the JPN Guidelines for the Management of Acute Pancreatitis. A Working Group of 20 physicians specializing in pancreatic diseases and emergency medicine investigated and analyzed 14821 cases retrieved by means of a Medline (1960–2004) search and discussed the available literature on acute pancreatitis (limited to human pancreatitis). The Working Group held many general discussions in order to reach a consensus on the content of the Guidelines. After producing a draft, the Publishing Committee of the JPN Guidelines for the Management of Acute Pancreatitis posted it on a website and asked for comments and criticisms. Subsequently, a final version of the Guidelines was published in Japanese in 2003. The Publishing Committee is now making the Guidelines available to a much wider readership by bringing out an English version.

Gallstone Pancreatitis – Who Really Needs an ERCP?

Gallstone Pancreatitis – Who Really Needs an ERCP?

Acute biliary pancreatitis: when should the endoscopist intervene?

A 63-year-old usman is admitted to the hospital with acute pancreatitis of presumed biliary origin. Laboratory results include white blood cell count (WBC) 18,500; hemoglobin 13.0; platelets 191,000; alanine aminotransferase (ALT) 330; aspartate aminotransferase (AST) 260; alkaline phosphatase 250; bilirubin 1.4; glucose 225; blood urea nitrogen (BUN) 47; creatinine 1.4; and prothrombin time 12 seconds. Ultrasound shows gallstones in the gallbladder; the common bile duct is 5 mm without stones identified.

Management of gallstone pancreatitis in Auckland: progress and compliance.

Recent advances in the management of acute gallstone pancreatitis include the introduction of laparoscopic cholecystectomy,defining the role of endoscopic retrograde cholangiopancreatography(ERCP) and early cholecystectomy to prevent recurrent pancreatitis. The aim of the present study was to review the current management of gallstone pancreatitis in Auckland Hospital, compare findings with a similar study published a decade ago and to determine the extent to which the management is compliant with recently published consensus guidelines. A retrospective review of consecutive patients admitted with acute pancreatitis during a 39-month study period was undertaken. Data were recorded regarding demographics, diagnosis, predicted and actual severity of gallstone pancreatitis (index and recurrent attacks), the role of ERCP and computed tomography scanning, the timing of cholecystectomy (open and laparoscopic), intraoperative cholangiography, duration of hospital stay, complications and mortality. : There were 216 patients admitted with acute pancreatitis,106 of whom had proven gallstones. An ERCP was performed in 62(59%) patients with gallstone pancreatitis but not more commonly in patients with severe pancreatitis, and common bile duct stones were identified in 26% of these patients. Of the 70 (66%)patients who had a cholecystectomy, 56 (80%) had it within 3 weeks of admission. Although the proportion of patients with gallstone pancreatitis who had a cholecystectomy is similar to the earlier study, there has been a significant increase in the proportion of patients having a cholecystectomy during the index admission (chi2 = 3.83; P = 0.05). This has resulted in a reduction in recurrent pancreatitis (P < 0.001). Although the overall mortality from gallstone pancreatitis has not significantly decreased, it has for patients with predicted severe gallstone pancreatitis (P = 0.02). : There has been reasonable compliance with published guidelines and some progress in the management of gallstone pancreatitis,particularly in relation to performing timely laparoscopic cholecystectomy with a reduction in the incidence of recurrent pancreatitis. Concerns remain regarding the overuse of diagnostic ERCP in patients with mild pancreatitis.

Management of gallstone pancreatitis: Cholecystectomy or ERCP and endoscopic sphincterotomy

Background: Currently, cholecystectomy is recommended for patients with gallstone-induced pancreatitis. ERCP with endoscopic sphincterotomy (ES) within 24 to 48 hours is also suggested for the treatment of acute gallstone pancreatitis. The aim of this study was to determine outcome after cholecystectomy versus ES alone in patients with gallstone pancreatitis. Methods: One hundred seventeen patients with gallstone pancreatitis were included in this prospective observational study. Inclusion criteria were typical abdominal pain; serum amylase level 3 times or greater than normal; and gallbladder stones and a dilated bile duct, with or without stones, by US, CT, or ERCP. Results: Eighty-three patients (Group A) underwent cholecystectomy after initial evaluation including ERCP in 43 (53%) and ERCP with ES in 38 (47%). The remaining 34 (Group B) underwent successful ERCP with ES alone. Mean follow-up was 33 months for Group A and 34 months for Group B. Recurrent gallstone pancreatitis was noted in 2 patients (2.4%) in Group A (bile duct stone in 2, sludge and papillary stenosis in 1), and in 1 patient (2.9%) in Group B. Ten patients in Group B had follow-up US of the gallbladder that showed disappearance of stones in 3. During follow-up, there was no significant difference in the rates of biliary complications (Group A, 3.6% vs. Group B, 11.6%; p = 0.19) or serious complications (pancreatitis, cholecystitis, cholangitis) (Group A, 3.6% vs. Group B, 5.8%). Also, there was no significant difference in procedure-related complications. Conclusions: Recurrence of pancreatitis after ERCP with ES alone for gallstone pancreatitis is rare. In patients who have undergone ES alone, cholecystectomy should be considered only if there are overt manifestations of gallbladder disease (e.g., biliary pain, cholecystitis, cystic duct obstruction) and not for prevention of recurrent gallstone pancreatitis. Because treatment by ES alone may be associated with a higher risk of biliary complications during follow-up compared with cholecystectomy, these patients may require close surveillance. (Gastrointest Endosc 2002;56:61-5.)

Current diagnosis and management of gallstone pancreatitis

Acute pancreatitis is a common disorder encountered frequently in all general surgical practices. Gallstones and alcohol abuse together account for more than 80% of the cases, with anywhere from 30% to 75% because of gallstones. The rest are because of diverse causes, including hyperlipidemia, medications, hypercalcemia, trauma, familial pancreatitis, and other rare origins. Approximately 10% to 15% of the United States population have gallstones; risk factors include advanced age, female sex, obesity, weight loss, and pregnancy. Pancreatitis occurs in 3% to 8% of all patients with symptomatic gallstones. The management of gallstone pancreatitis remains challenging, even though most patients have self-limiting disease that can be treated effectively. Severe pancreatitis only occurs in a few patients, but it is associated with a mortality rate as high as 45% to 100%; so the overall mortality rate for pancreatitis is approximately 10%.

4678 Management of gallstone pancreatitis: cholecystectomy or ercp and endoscopic sphincterotomy.

Background: Currently, laparoscopic (lap.) CCX is the recommended treatment of gallstone pancreatitis. ERCP and ES within 24-48 hours is suggested in the treatment of acute biliary pancreatitis. Aim: To assess role of lap. CCX after ERCP and ES in patients with gallstone pancreatitis. Methods: 118 patients with gallstone pancreatitis (mean age: 44, range: 18-68 yrs.), 102-F, 16-M were identified. Inclusion criteria were typical abdominal pain, serum amylase ≥ twice normal (normal ≤ 128), and gallbladder (GB) stones, dilated common bile duct (CBD) ±CBD stone by ultrasound (US), CT scan or ERCP. Results: 81 patients underwent CCX after initial evaluation including ERCP in 43 (53%) and ERCP + ES in 38 (47%). Of the 34 patients with no CCX, 33 underwent successful ERCP + ES only . Mean follow-up was 22 months (range 8-49). Recurrent pancreatitis was seen in 3 (3.7%) in CCX group (CBD stone in 2, papillary stenosis in 1), and in 2 (5.8%) in ERCP + ES only group (CBD stone and papillary restenosis in one, alcohol induced in other - this patient also had cholecystitis). 10 patients in ERCP + ES only group had follow-up US and showed persistent GB stones in 8 and disappearance of GB stones in 2. Procedure related complications included one patient with cystic duct leak in CCX group and one with mild ERCP induced pancreatitis in ERCP + ES only group. Conclusions: Recurrent pancreatitis after ERCP + ES only for gallstone pancreatitis is rare. In patients who have undergone ERCP + ES only for gallstone pancreatitis, CCX should be considered only in presence of symptomatic GB disease such as cholecystitis, cystic duct obstruction, etc. and not just to prevent recurrent gallstone pancreatitis.

The management of gallstone pancreatitis in the era of laparoscopic cholecystectomy

W hen we wrote an editorial opinion 5 years ago on the proper timing of surgery in gallstone pancreatitis, we never dreamed how much the advent of laparoscopic cholecystectomy in 1989 would change current management. For the traditional open cholecystectomy and cholangiogram we recommended a delay of at least 3 days in the more severe cases to allow acute symptoms to subside, but operation before hospital charge.’ Now immediate endoscopic retrograde cholangiopancreatography (ERCP) is being widely urged to abort the acute attack. It is also being performed with increasing frequency because laparoscopic cholecystectomy is planned. The indications for urgent ERCP are very limited in gallstone pancreatitis. In the retrospective reviews of experience with this procedure, including sphincterotomy and stone extraction if needed, the benefits are uncertain and the complication rate is the expected 3-4%. Two comprehensive, prospective, and randomized studies of early ERCP have been published. In both studies the cases were stratified into mild and severe groups. Both included sphincteroplasty and stone extraction whenever stones were encountered. In both studies early ERCP did not alter the course of mild pancreatitis. In severe pancreatitis, Fan and colleagues found fewer bouts of septic cholangitis (0% vs 12%) when ERCP was performed within the first 24 hours. This was the only statistically significant benefit. This study was conducted in Hong Kong, where many patients have large soft primary stones in the common duct, so that these results may not be applicable to a non-Asian population. Neoptolemos and colleagues conducted their studies in England, where ERCP within 72 hours reduced complications significantly ( 18% of 22 cases having ERCP, vs 54% of 24 cases treated conventionally), but only in the severe cases.“’ These are relatively small numbers, so that more time and cases are needed. These results differ from the results in a randomized study of timing for open cholecystectomy. In both severe and mild cases the removal of an impacted ampullary stone did not ameliorate the progression of the pancreatitis.4

Management of Gallstone Pancreatitis during pregnancy and the Postpartum Period

Department of Surgery, Akron City Hospital, Northeastern Ohio Universities College of Medicine, Akron, Ohio

Endoscopic sphincterotomy in the management of gallstone pancreatitis.

The presence of pancreatitis does not constitute a contraindication to endoscopic sphincterotomy in the management of common duct calculi. On the contrary, experience with 10 cases of gallstone pancreatitis suggests that endoscopic sphincterotomy can be carried out safely with little disturbance to the patient, and that it greatly simplifies the management of these cases. In the frail and elderly patient little further may be required.