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Stefanova I, Kyle E, Wilson I, Tobbal M, Veeramootoo D, De'Ath HD. Laparoscopic Cholecystectomy vs Endoscopic Retrograde Cholangiopancreatography With Sphincterotomy in Elderly Patients With Acute Gallstone Pancreatitis. Am Surg 2024; 90:2808-2813. [PMID: 38636538 DOI: 10.1177/00031348241248564] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 04/20/2024]
Abstract
BACKGROUND Gallstone pancreatitis (GSP) is common in elderly patients and carries worse outcomes. Laparoscopic cholecystectomy (LC) is recommended for prevention of recurrent GSP. In frail populations, an endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-s) is an alternative. Management guidelines of GSP in the elderly are lacking. This study aimed to investigate and compare management strategies for GSP in the elderly. MATERIALS AND METHODS A retrospective comparison of outcome of patients aged ≥65 years with first presentation of GSP treated either with (1) LC only, (2) ERCP-s, (3) ERCP-S followed by LC, or (4) no intervention. RESULTS 216 patients were included. Median age was 76 years (interquartile range 70-83). Most (80%, n = 172) had mild pancreatitis, whilst 12% (n = 26) had severe disease. 24% (n = 55) were treated with ERCP-s; 40% (n = 87) underwent LC alone; 11% (n = 23) had ERCP-s followed by LC; and 25% (n = 55) received no intervention. Patients without intervention were older (P < .001) and frailer (P < .001). The LC-only group had lower post-procedure re-admission rates of 6% (n = 5) compared to 27% (n = 14) for ERCP-s, 33% (n = 7) for ERCP-S + LC, and 31% (n = 17) for the no intervention group (P = .0001). Biliary cause mortality was highest in the no intervention group (n = 11, 20%). CONCLUSION Laparoscopic cholecystectomy represents the gold standard for elderly patients with GSP.
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Affiliation(s)
- Irena Stefanova
- Department of Upper Gastrointestinal Surgery, Royal Surrey County Hospital, Egerton Road, Guildford, UK
| | - Ewan Kyle
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Iain Wilson
- Department of Upper Gastrointestinal Surgery, Wexham Park Hospital, Wexham St, Slough, UK
| | - Muhammad Tobbal
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Darmarajah Veeramootoo
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
| | - Henry D De'Ath
- Department of Upper Gastrointestinal Surgery, Frimley Park Hospital, Portsmouth Road, Camberley, UK
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Gagyi EB, Teutsch B, Veres DS, Pálinkás D, Vörhendi N, Ocskay K, Márta K, Hegyi PJ, Hegyi P, Erőss B. Incidence of recurrent and chronic pancreatitis after acute pancreatitis: a systematic review and meta-analysis. Therap Adv Gastroenterol 2024; 17:17562848241255303. [PMID: 38883160 PMCID: PMC11179553 DOI: 10.1177/17562848241255303] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/09/2023] [Accepted: 04/26/2024] [Indexed: 06/18/2024] Open
Abstract
Background Acute pancreatitis (AP) has a high incidence, and patients can develop recurrent acute pancreatitis (RAP) and chronic pancreatitis (CP) after AP. Objectives We aimed to estimate the pooled incidence rates (IRs), cumulative incidences, and proportions of RAP and CP after AP. Design A systematic review and meta-analysis of studies reporting the proportion of RAP and CP after AP. Data sources and methods The systematic search was conducted in three (PubMed, EMBASE, and CENTRAL) databases on 19 December 2023. Articles reporting the proportion of RAP or CP in patients after the first and multiple episodes of AP were eligible. The random effects model was used to calculate the pooled IR with 95% confidence intervals (CIs). The I 2 value assessed heterogeneity. The risk of bias assessment was conducted with the Joanna Briggs Institute Critical Appraisal Tool. Results We included 119 articles in the quantitative synthesis and 29 in the IRs calculations. Our results showed that the IR of RAP in adult patients after AP was 5.26 per 100 person-years (CI: 3.99-6.94; I 2 = 93%), while in children, it was 4.64 per 100 person-years (CI: 2.73-7.87; I 2 = 88%). We also found that the IR of CP after AP was 1.4 per 100 person-years (CI: 0.9-2; I 2 = 75%), while after RAP, it increased to 4.3 per 100 person-years (CI: 3.1-6.0; I 2 = 76%). The risk of bias was moderate in the majority of the included studies. Conclusion Our results showed that RAP affects many patients with AP. Compared to patients with the first AP episode, RAP leads to a threefold higher IR for developing CP. Trial registration Our protocol was registered on PROSPERO (CRD42021283252).
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Affiliation(s)
- Endre-Botond Gagyi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Selye János Doctoral College for Advanced Studies, Semmelweis University, Budapest, Hungary
| | - Brigitta Teutsch
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Dániel Sándor Veres
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Biophysics and Radiation Biology, Semmelweis University, Budapest, Hungary
| | - Dániel Pálinkás
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Department of Gastroenterology, Military Hospital Medical Centre, Hungarian Defense Forces, Budapest, Hungary
| | - Nóra Vörhendi
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Klementina Ocskay
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
| | - Katalin Márta
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Péter Jenő Hegyi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Péter Hegyi
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
- Institute for Pancreatic Diseases, Semmelweis University, Budapest, Hungary
| | - Bálint Erőss
- Institute for Pancreatic Diseases, Semmelweis University, Budapest, Hungary
- Center for Translational Medicine, Semmelweis University, Budapest, Hungary
- Institute for Translational Medicine, Medical School, University of Pécs, Pécs, Hungary
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Mc Geehan G, Melly C, O' Connor N, Bass G, Mohseni S, Bucholc M, Johnston A, Sugrue M. Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis. Eur J Trauma Emerg Surg 2023; 49:2257-2267. [PMID: 36053288 PMCID: PMC10520076 DOI: 10.1007/s00068-022-02070-2] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/04/2022] [Accepted: 08/05/2022] [Indexed: 11/03/2022]
Abstract
BACKGROUND Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach. METHODS A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies. RESULTS 13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07-0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26-1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16-0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis. CONCLUSIONS In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.
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Affiliation(s)
- Gearóid Mc Geehan
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland.
- School of Medicine, University of Limerick, Limerick, Ireland.
| | - Conor Melly
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- School of Medicine, University of Limerick, Limerick, Ireland
| | - Niall O' Connor
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
| | - Gary Bass
- Division of Traumatology, Emergency Surgery and Surgical Critical Care, University of Pennsylvania, Philadelphia, USA
| | - Shahin Mohseni
- Department of Trauma and Emergency Surgery, Orebro University Hospital and School of Medical Sciences, Orebro University, Orebro, Sweden
| | - Magda Bucholc
- Intelligent Systems Research Centre, School of Computing, Engineering and Intelligent Systems, Ulster University (European Union Interreg VA Funded), Magee Campus, Northern Ireland, UK
| | - Alison Johnston
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
| | - Michael Sugrue
- Donegal Clinical Research Academy, Letterkenny University Hospital, Donegal, Ireland
- Department of Surgery, Letterkenny University Hospital, Letterkenny, Co Donegal, Ireland
- EU INTERREG Emergency Surgery Outcome Advancement Project, Centre for Personalised Medicine, Letterkenny, Ireland
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Pancreatic Disorders of Pregnancy. Clin Obstet Gynecol 2021; 63:226-242. [PMID: 31789887 DOI: 10.1097/grf.0000000000000503] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/24/2022]
Abstract
The pancreas is an organ with both exocrine and endocrine functions that has a vital role in both digestion as well as glucose metabolism. Although pancreatic dysfunction and disorders are rare in pregnancy, they are becoming increasingly more common. Recognition of these disorders and understanding how they can affect pregnancy is imperative to allow for proper management. We provide an overview of the most common pancreatic disorders that are seen in pregnancy.
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Liao WC, Tu TC, Lee KC, Tseng JH, Chen MJ, Sun CK, Wang SY, Chang WK, Chang PY, Wu MS, Lin TJ, Lee HL, Chen JH, Yuan KC, Liu NJ, Wu HC, Liang PC, Wang HP, Hwang TL, Lee CL. Taiwanese consensus recommendations for acute pancreatitis. J Formos Med Assoc 2020; 119:1343-1352. [PMID: 31395463 DOI: 10.1016/j.jfma.2019.07.019] [Citation(s) in RCA: 6] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/06/2019] [Revised: 06/11/2019] [Accepted: 07/17/2019] [Indexed: 12/12/2022] Open
Abstract
The incidence of acute pancreatitis and related health care utilization are increasing. Acute pancreatitis may result in organ failure and various local complications with risks of morbidity and even mortality. Recent advances in research have provided novel insights into the assessment and management for acute pancreatitis. This consensus is developed by Taiwan Pancreas Society to provide an updated, evidence-based framework for managing acute pancreatitis.
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Affiliation(s)
- Wei-Chih Liao
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tien-Chien Tu
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan
| | - Kuei-Chuan Lee
- Division of Gastroenterology and Hepatology, Department of Medicine, Taipei Veterans General Hospital, Taipei, Taiwan
| | - Jseng-Hwei Tseng
- Department of Imaging & Intervention, Chang Gung Memorial Hospital, Linkou, Taiwan
| | - Ming-Jen Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, MacKay Memorial Hospital, Taipei, Taiwan
| | - Cheuk-Kay Sun
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Shin Kong Wu Ho-Su Memorial Hospital, Taipei, Taiwan
| | - Shang-Yu Wang
- Division of Trauma and Emergency Surgery, Department of Surgery, Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Wei-Kuo Chang
- Division of Gastroenterology, Department of Internal Medicine, Tri-Service General Hospital, Taiwan
| | - Pi-Yi Chang
- Department of Radiology, Taichung Veterans General Hospital, Taiwan
| | - Ming-Shun Wu
- Division of Gastroenterology, Department of Internal Medicine, Wan Fang Hospital, College of Medicine, Taipei Medical University, Taipei, Taiwan
| | - Tsung-Jung Lin
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei City Hospital, Ren-Ai Branch, Taipei, Taiwan
| | - Hsiang-Lin Lee
- Department of Surgery, Chung Shan Medical University Hospital, Institute of Medicine4, Chung Shan Medical University, Taichung, Taiwan
| | - Jiann-Hwa Chen
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Taipei Tzu Chi Hospital, Taipei, Taiwan
| | - Kuo-Ching Yuan
- Division of Acute Care Surgery and Trauma, Department of Surgery, Taipei Medical University Hospital, Taiwan
| | - Nai-Jen Liu
- Department of Gastroenterology and Hepatology, Linkou Chang Gung Memorial Hospital, Taoyuan, Taiwan
| | - Hsing-Chien Wu
- Department of Internal Medicine, Taipei Hospital, Ministry of Health and Welfare, Taiwan
| | - Po-Chin Liang
- Department of Medical Imaging, National Taiwan University Hospital, Taiwan
| | - Hsiu-Po Wang
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, National Taiwan University Hospital, National Taiwan University College of Medicine, Taipei, Taiwan; Internal Medicine, College of Medicine, National Taiwan University, Taipei, Taiwan
| | - Tsann-Long Hwang
- Department of Surgery, Chang Gung Memorial Hospital, Chang Gung University, Lin-Kou, Taiwan
| | - Chia-Long Lee
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Cathay General Hospital, Taipei, Taiwan.
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Cho JH, Jeong YH, Kim KH, Kim TN. Risk factors of recurrent pancreatitis after first acute pancreatitis attack: a retrospective cohort study. Scand J Gastroenterol 2020; 55:90-94. [PMID: 31822144 DOI: 10.1080/00365521.2019.1699598] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/08/2023]
Abstract
Background and aims: Few studies have been conducted in Asia on the recurrence of acute pancreatitis (AP). This study was designed to investigate characteristics of the disease to predict recurrence.Methods: We retrospectively analyzed 617 patients that experienced a first AP attack between January 2009 and December 2014. Based on reviews of clinical and follow-up data, we attempted to identify risk factors of recurrence using Cox regression analysis.Results: During a median follow-up of 3.2 years (range 3-72 months), 100(16.2%) of the 617 study subjects experienced one or more episodes of recurrent acute pancreatitis (RAP). Of these 100 patients, 75(75%) experienced one relapse, 12(12%) two relapses, and 13(13%) three or more relapses. The etiologies of RAP were an alcohol (48%), gallstone (31%), idiopathic (14%), and others (7%). Univariate analysis showed that an age of <60 years, male gender, smoking, an alcohol-associated etiology, and a local complication at index admission were significant risk factors of RAP. Cox regression analysis showed that an age of <60 years (HR = 1.602, 95% CI: 1.029-2.493), male gender (HR = 1.927, 95% CI: 1.127-3.295), and the presence of a local complication (HR = 3.334, 95% CI: 2.211-5.026) were significant risk factors of RAP development.Conclusion: A local complication at index admission was found to be the strongest risk factor of RAP, and a male gender and an age of <60 years were significantly associated with RAP. Special attention and close follow-up should be afforded to patients with a local complication at index admission or male patients <60 years old.
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Affiliation(s)
- Joon Hyun Cho
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Yo Han Jeong
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Kook Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, Daegu, Republic of Korea
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García de la Filia Molina I, García García de Paredes A, Martínez Ortega A, Marcos Carrasco N, Rodríguez De Santiago E, Sánchez Aldehuelo R, Foruny Olcina JR, González Martin JÁ, López Duran S, Vázquez Sequeiros E, Albillos A. Biliary sphincterotomy reduces the risk of acute gallstone pancreatitis recurrence in non-candidates for cholecystectomy. Dig Liver Dis 2019; 51:1567-1573. [PMID: 31151894 DOI: 10.1016/j.dld.2019.05.007] [Citation(s) in RCA: 12] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/01/2019] [Revised: 04/28/2019] [Accepted: 05/01/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND Population aging and comorbidity are leading to an increase in patients unfit for cholecystectomy. AIMS To evaluate whether endoscopic biliary sphincterotomy after a first episode of acute gallstone pancreatitis reduces the risk of pancreatitis recurrence and gallstone-related events in non-surgical candidates. METHODS Retrospective study of patients admitted for a first episode of acute gallstone pancreatitis rejected for cholecystectomy between 2013-2018. The role of endoscopic sphincterotomy was evaluated by adjusting for age, severity of pancreatitis, and presence of choledocholithiasis. RESULTS We included 247 patients (mean age 80 ± 12 years; Charlson index: 5; severity of pancreatitis: 72% mild). Sphincterotomy was performed in 23.9%. Recurrence of pancreatitis occurred in 17.4% patients (median follow-up: 426 days). The one-year cumulative incidence of a new episode of pancreatitis was 1.8% (95% confidence interval [CI]: 0.2-12%) and 23% (95% CI: 17-31%) in patients with and without sphincterotomy, respectively (p = 0.006). In multivariate analysis, sphincterotomy showed a protective role for recurrence of pancreatitis (adjusted hazard ratio [HR]: 0.29, 95% CI: 0.08-0.92, p = 0.037) and for any gallstone-related event (HR 0.46, 95% CI: 0.21-0.98, p = 0.043). CONCLUSIONS Endoscopic biliary sphincterotomy reduced the risk of gallstone pancreatitis recurrence and other biliary-related disorders in patients with a first episode of pancreatitis non-candidates for cholecystectomy.
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Affiliation(s)
- Irene García de la Filia Molina
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Ana García García de Paredes
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain.
| | - Antonio Martínez Ortega
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Natalia Marcos Carrasco
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Enrique Rodríguez De Santiago
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Rubén Sánchez Aldehuelo
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Jose Ramón Foruny Olcina
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Juan Ángel González Martin
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Sergio López Duran
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain
| | - Enrique Vázquez Sequeiros
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain
| | - Agustín Albillos
- Gastroenterology and Hepatology Department, Ramón y Cajal University Hospital, Madrid, Spain; University of Alcalá, Madrid, Spain; Ramón y Cajal Institute of Biosanitary Research (IRYCIS), Madrid, Spain; Biomedical Research Center in Liver and Digestive Diseases Network (CIBERehd), Carlos III Health Institute, Madrid, Spain
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Kim SB, Kim TN, Chung HH, Kim KH. Small Gallstone Size and Delayed Cholecystectomy Increase the Risk of Recurrent Pancreatobiliary Complications After Resolved Acute Biliary Pancreatitis. Dig Dis Sci 2017; 62:777-783. [PMID: 28035552 DOI: 10.1007/s10620-016-4428-3] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/13/2016] [Accepted: 12/19/2016] [Indexed: 12/12/2022]
Abstract
INTRODUCTION Acute biliary pancreatitis (ABP) is a severe complication of gallstone disease with considerable mortality, and its recurrence rate is reported as 50-90% for ABP patients who do not undergo cholecystectomy. However, the incidence of and risk factors for recurrent pancreatobiliary complications after the initial improvement of ABP are not well established in the literature. The aims of this study were to determine the risk factors for recurrent pancreatobiliary complications and to compare the outcomes between early (within 2 weeks after onset of pancreatitis) and delayed cholecystectomy in patients with ABP. METHODS Patients diagnosed with ABP at Yeungnam University Hospital from January 2004 to July 2016 were retrospectively reviewed. The following risk factors for recurrent pancreatobiliary complications (acute pancreatitis, acute cholecystitis, and acute cholangitis) were analyzed: demographic characteristics, laboratory data, size and number of gallstones, severity of pancreatitis, endoscopic sphincterotomy, and timing of cholecystectomy. Patients were categorized into two groups: patients with recurrent pancreatobiliary complications (Group A) and patients without pancreatobiliary complications (Group B). RESULTS Of the total 290 patients with ABP (age 66.8 ± 16.0 years, male 47.9%), 56 (19.3%) patients developed recurrent pancreatobiliary complications, of which 35 cases were acute pancreatitis, 11 cases were acute cholecystitis, and 10 cases were acute cholangitis. Endoscopic sphincterotomy and cholecystectomy were performed in 134 (46.2%) patients and 95 (32.8%) patients, respectively. Age, sex, BMI, diabetes, number of stone, severity of pancreatitis, and laboratory data were not significantly correlated with recurrent pancreatobiliary complications. The risk of recurrent pancreatobiliary complications was significantly increased in the delayed cholecystectomy group compared with the early cholecystectomy group (45.5 vs. 5.0%, p < 0.001). Based on the multivariate logistic regression analyses, two factors, size of gallstone less than or equal to 5 mm and delayed cholecystectomy, were found as risk factors associated with recurrent pancreatobiliary complications. CONCLUSION The incidence of recurrent pancreatobiliary complications was 19.3% and was significantly increased in patients with size of gallstone less than or equal to 5 mm and in those who underwent delayed cholecystectomy.
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Affiliation(s)
- Sung Bum Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea
| | - Tae Nyeun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea.
| | - Hyun Hee Chung
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea
| | - Kook Hyun Kim
- Division of Gastroenterology and Hepatology, Department of Internal Medicine, Yeungnam University College of Medicine, 317-1 Daemyung-dong, Nam-gu, Daegu, 705-717, Republic of Korea
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Lee JM, Chung WC, Sung HJ, Kim YJ, Youn GJ, Jung YD, Choi S, Jeon EJ. Factor analysis of recurrent biliary events in long-term follow up of gallstone pancreatitis. J Dig Dis 2017; 18:40-46. [PMID: 27990758 DOI: 10.1111/1751-2980.12436] [Citation(s) in RCA: 2] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 09/23/2016] [Revised: 12/03/2016] [Accepted: 12/13/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVE Recurrent attacks after acute gallstone pancreatitis (GSP) are substantial problems, together with associated morbidity and mortality. The recommended therapies for recurrent attacks are cholecystectomy and endoscopic sphincterotomy (EST). This study aimed to evaluate the long-term results of cholecystectomy and EST after clinical improvement of GSP. METHODS A consecutive series of patients who were admitted with GSP from January 2003 to December 2014 were analyzed. Patients were categorized into three treatment subgroups: cholecystectomy (n = 53), EST (n = 51) and conservative care (n = 67). RESULTS A total of 171 patients were enrolled. The mean follow-up period was 58 months (range 6-125 months). The pancreatitis-induced in-hospital mortality rate was 1.5%. The cholecystectomy and EST groups had a significantly lower frequency of recurrent pancreatitis than the conservative care group (P < 0.01). For recurrent pancreatitis, there was no significant difference between the cholecystectomy with and without EST subgroups. With respect to total recurrent biliary events, the cholecystectomy group was superior to the EST only group (P < 0.01). In patients receiving definitive treatment (cholecystectomy with or without EST), the presence of common bile duct (CBD) stone was an independent risk factor for recurrent biliary events (P < 0.01). CONCLUSIONS In the long-term follow up of GSP, cholecystectomy can offer better protection against recurrent biliary events than EST only. The presence of CBD stones at time of definitive therapy might be a risk factor for recurrent biliary events.
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Affiliation(s)
- Ji Min Lee
- Division of Gastroenterology, Department of Internal Medicine, St Vincent Hospital, Catholic University of Korea, Suwon, South Korea
| | - Woo Chul Chung
- Division of Gastroenterology, Department of Internal Medicine, St Vincent Hospital, Catholic University of Korea, Suwon, South Korea
| | - Hea Jung Sung
- Division of Gastroenterology, Department of Internal Medicine, St Vincent Hospital, Catholic University of Korea, Suwon, South Korea
| | - Yeon-Ji Kim
- Division of Gastroenterology, Department of Internal Medicine, St Vincent Hospital, Catholic University of Korea, Suwon, South Korea
| | - Gun Jung Youn
- Division of Gastroenterology, Department of Internal Medicine, St Vincent Hospital, Catholic University of Korea, Suwon, South Korea
| | - Yun Duk Jung
- Division of Gastroenterology, Department of Internal Medicine, St Vincent Hospital, Catholic University of Korea, Suwon, South Korea
| | - Sooa Choi
- Division of Gastroenterology, Department of Internal Medicine, St Vincent Hospital, Catholic University of Korea, Suwon, South Korea
| | - Eun Jung Jeon
- Division of Gastroenterology, Department of Internal Medicine, St Paul's Hospital, Catholic University of Korea, Seoul, South Korea
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Başak F, Tardu A, Sevinç MM, Kınacı E, Aren A. Rekürren biliyer pankreatit nasıl önlenebilir? Olgu sunumu ve literatür derlemesi. ARCHIVES OF CLINICAL AND EXPERIMENTAL MEDICINE 2016. [DOI: 10.25000/acem.292888] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/23/2022] Open
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Outcomes of early versus delayed cholecystectomy in patients with mild to moderate acute biliary pancreatitis: A randomized prospective study. Asian J Surg 2016; 41:47-54. [PMID: 27530927 DOI: 10.1016/j.asjsur.2016.07.010] [Citation(s) in RCA: 30] [Impact Index Per Article: 3.3] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2016] [Revised: 05/26/2016] [Accepted: 05/30/2016] [Indexed: 01/29/2023] Open
Abstract
BACKGROUND In patients with acute biliary pancreatitis (ABP), cholecystectomy is mandatory to prevent further biliary events, but the precise timing of cholecystectomy for mild to moderate disease remain a subject of ongoing debate. The aim of this study is to assess the outcomes of early versus delayed cholecystectomy. We hypothesize that early cholecystectomy as compared to delayed cholecystectomy reduces recurrent biliary events without a higher peri-operative complication rate. METHODS Patients with mild to moderate ABP were prospectively randomized to either an early cholecystectomy versus a delayed cholecystectomy group. Recurrent biliary events, peri-operative complications, conversion rate, length of surgery and total hospital length of stay between the two groups were evaluated. RESULTS A total of 72 patients were enrolled at a single public hospital. Of them, 38 were randomized to the early group and 34 patients to the delayed group. There were no differences regarding peri-operative complications (7.78% vs 11.76%; p = 0.700), conversion rate to open surgery (10.53% vs 11.76%; p = 1.000) and duration of surgery performed (80 vs 85 minutes, p = 0.752). Nevertheless, a greater rate of recurrent biliary events was found in the delayed group (44.12% vs 0%; p ≤ 0.0001) and the hospital length of stay was longer in the delayed group (9 vs 8 days, p = 0.002). CONCLUSION In mild to moderate ABP, early laparoscopic cholecystectomy reduces the risk of recurrent biliary events without an increase in operative difficulty or perioperative morbidity.
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Harris HW, Davis BR, Vitale GC. Cholecystectomy After Endoscopic Sphincterotomy for Common Bile Duct Stones: Is Surgery Necessary? Surg Innov 2016; 12:187-94. [PMID: 16224638 DOI: 10.1177/155335060501200302] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/17/2022]
Abstract
It has been more than 30 years since the introduction of endoscopic sphincterotomy for the management of choledocholithiasis. Once introduced, this endoscopic intervention subsequently enabled clinicians to witness the natural history of leaving the gallbladder in situ once the common duct calculi were removed. Because many people were free of symptoms once the common bile duct was cleared of stones, patients and physicians alike soon questioned whether it was necessary to remove the gallbladder at all. Despite more than two decades of clinical research and numerous published reports, the answer to this question remains elusive. Similarly, the management algorithm for choledocholithiasis in patients with an intact gallbladder remains controversial. We review the available key data regarding this question. Importantly, there are only three prospective, randomized trials that have examined the need for cholecystectomy after endoscopic sphincterotomy, with case studies constituting most of the published reports. Consequently, the literature on this topic remains inconclusive, weakened by its retrospective approach, considerable variability between the patients studied, inconsistent inclusion and exclusion criteria, and frequently poor patient follow-up. Nonetheless, the preponderance of data favor removing the gallbladder after endoscopically clearing the common bile duct of gallstones because an estimated 25% of patients will experience recurrent symptoms within a 2-year follow up period. Recognizing the existence of various mitigating clinical factors, we advocate adopting a selective wait-and-see approach for high-risk patients, especially those with a life expectancy of less than 2 years or severely debilitating comorbidities.
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Affiliation(s)
- Hobart W Harris
- Division of General Surgery, University of California, San Francisco, San Francisco, CA, USA
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Ahn DW. [The Protective Role of Endoscopic Sphincterotomy and/or Cholecystectomy for Recurrence of Acute Biliary Pancreatitis]. THE KOREAN JOURNAL OF GASTROENTEROLOGY 2015. [PMID: 26219107 DOI: 10.4166/kjg.2015.65.5.265] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/03/2022]
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Abstract
The medical treatment of acute pancreatitis continues to focus on supportive care, including fluid therapy, nutrition, and antibiotics, all of which will be critically reviewed. Pharmacologic agents that were previously studied were found to be ineffective likely due to a combination of their targets and flaws in trial design. Potential future pharmacologic agents, particularly those that target intracellular calcium signaling, as well as considerations for trial design will be discussed. As the incidence of acute pancreatitis continues to increase, greater efforts will be needed to prevent hospitalization, readmission and excessive imaging in order to reduce overall healthcare costs. Primary prevention continues to focus on post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and secondary prevention on cholecystectomy for biliary pancreatitis as well as alcohol and smoking abstinence.
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Affiliation(s)
- Vikesh K Singh
- Pancreatitis Center, Division of Gastroenterology, Johns Hopkins University School of Medicine, Baltimore, MD, USA
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Yokoe M, Takada T, Mayumi T, Yoshida M, Isaji S, Wada K, Itoi T, Sata N, Gabata T, Igarashi H, Kataoka K, Hirota M, Kadoya M, Kitamura N, Kimura Y, Kiriyama S, Shirai K, Hattori T, Takeda K, Takeyama Y, Hirota M, Sekimoto M, Shikata S, Arata S, Hirata K. Japanese guidelines for the management of acute pancreatitis: Japanese Guidelines 2015. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2015; 22:405-432. [PMID: 25973947 DOI: 10.1002/jhbp.259] [Citation(s) in RCA: 279] [Impact Index Per Article: 27.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 04/07/2015] [Accepted: 04/10/2015] [Indexed: 12/18/2022]
Abstract
BACKGROUND Japanese (JPN) guidelines for the management of acute pancreatitis were published in 2006. The severity assessment criteria for acute pancreatitis were later revised by the Japanese Ministry of Health, Labour and Welfare (MHLW) in 2008, leading to their publication as the JPN Guidelines 2010. Following the 2012 revision of the Atlanta Classifications of Acute Pancreatitis, in which the classifications of regional complications of pancreatitis were revised, the development of a minimally invasive method for local complications of pancreatitis spread, and emerging evidence was gathered and revised into the JPN Guidelines. METHODS A comprehensive evaluation was carried out on the evidence for epidemiology, diagnosis, severity, treatment, post-endoscopic retrograde cholangiopancreatography (ERCP) pancreatitis and clinical indicators, based on the concepts of the GRADE system (Grading of Recommendations Assessment, Development and Evaluation). With the graded recommendations, where the evidence was unclear, Meta-Analysis team for JPN Guidelines 2015 conducted an additional new meta-analysis, the results of which were included in the guidelines. RESULTS Thirty-nine questions were prepared in 17 subject areas, for which 43 recommendations were made. The 17 subject areas were: Diagnosis, Diagnostic imaging, Etiology, Severity assessment, Transfer indication, Fluid therapy, Nasogastric tube, Pain control, Antibiotics prophylaxis, Protease inhibitor, Nutritional support, Intensive care, management of Biliary Pancreatitis, management of Abdominal Compartment Syndrome, Interventions for the local complications, Post-ERCP pancreatitis and Clinical Indicator (Pancreatitis Bundles 2015). Meta-analysis was conducted in the following four subject areas based on randomized controlled trials: (1) prophylactic antibiotics use; (2) prophylactic pancreatic stent placement for the prevention of post-ERCP pancreatitis; (3) prophylactic non-steroidal anti-inflammatory drugs (NSAIDs) for the prevention of post-ERCP pancreatitis; and (4) peritoneal lavage. Using the results of the meta-analysis, recommendations were graded to create useful information. In addition, a mobile application was developed, which made it possible to diagnose, assess severity and check pancreatitis bundles. CONCLUSIONS The JPN Guidelines 2015 were prepared using the most up-to-date methods, and including the latest recommended medical treatments, and we are confident that this will make them easy for many clinicians to use, and will provide a useful tool in the decision-making process for the treatment of patients, and optimal medical support. The free mobile application and calculator for the JPN Guidelines 2015 is available via http://www.jshbps.jp/en/guideline/jpn-guideline2015.html.
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Affiliation(s)
- Masamichi Yokoe
- General Internal Medicine, Japanese Red Cross Nagoya Daini Hospital, Nagoya, Japan
| | - Tadahiro Takada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Toshihiko Mayumi
- Department of Emergency Medicine, School of Medicine, University of Occupational and Environmental Health, KitaKyushu, Japan
| | - Masahiro Yoshida
- Department of Hemodialysis and Surgery, Chemotherapy Research Institute, International University of Health and Welfare, Ichikawa, Japan
| | - Shuji Isaji
- Hepatobiliary Pancreatic & Transplant Surgery Mie University Graduate School of Medicine, Mie, Japan
| | - Keita Wada
- Department of Surgery, Teikyo University School of Medicine, Tokyo, Japan
| | - Takao Itoi
- Department of Gastroenterology and Hepatology, Tokyo Medical University, Tokyo, Japan
| | - Naohiro Sata
- Department of Surgery, Jichi Medical University, Shimotsuke, Tochigi, Japan
| | - Toshifumi Gabata
- Department of Radiology, Kanazawa University, School of Medical Science, Kanazawa, Japan
| | - Hisato Igarashi
- Clinical Education Center, Kyushu University Hospital, Fukuoka, Japan
| | - Keisho Kataoka
- Otsu Municipal Hospital, Shiga
- Kyoto Prefectural University of Medicine, Kyoto, Japan
| | - Masahiko Hirota
- Department of Surgery, Kumamoto Regional Medical Center, Kumamoto, Japan
| | - Masumi Kadoya
- Department of Radiology, Shinshu University School of Medicine, Matsumoto, Japan
| | - Nobuya Kitamura
- Department of Emergency and Critical Care Medicine, Kimitsu Chuo Hospital, Kisarazu, Chiba, Japan
| | - Yasutoshi Kimura
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
| | - Seiki Kiriyama
- Department of Gastroenterology, Ogaki Municipal Hospital, Ogaki, Japan
| | - Kunihiro Shirai
- Department of Emergency and Critical Care Medicine, Ichinomiya Municipal Hospital, Ichinomiya, Japan
| | - Takayuki Hattori
- Department of Radiology, Tokyo Metropolitan Health and Medical Treatment Corporation, Ohkubo Hospital, Tokyo, Japan
| | - Kazunori Takeda
- Department of Surgery, National Hospital Organization Sendai Medical Center, Sendai, Japan
| | - Yoshifumi Takeyama
- Department of Surgery, Kinki University Faculty of Medicine, Osaka, Japan
| | - Morihisa Hirota
- Division of Gastroenterology, Tohoku University Graduate School of Medicine, Sendai, Japan
| | - Miho Sekimoto
- The University of Tokyo Graduate School of Public Policy, Health Policy Unit, Tokyo
| | - Satoru Shikata
- Department of Family Medicine, Mie Prefectural Ichishi Hospital, Mie, Japan
| | - Shinju Arata
- Gastroenterological Center, Yokohama City University Medical Center, Yokohama, Japan
| | - Koichi Hirata
- Department of Surgery, Surgical Oncology and Science, Sapporo Medical University, Sapporo, Japan
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Hu C, Shen SQ, Chen ZB. Treatment strategy for gallstone pancreatitis and the timing of cholecystectomy. World J Meta-Anal 2014; 2:42-48. [DOI: 10.13105/wjma.v2.i2.42] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 11/23/2013] [Revised: 01/18/2014] [Accepted: 03/04/2014] [Indexed: 02/05/2023] Open
Abstract
AIM: To reviewed the literature and evaluated the scope and timing of the application of endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (ES) and cholecystectomy.
METHODS: A pooled odds ratio (OR) and a pooled mean difference with the 95%CI were used to assess the enumeration data of included studies. A pooled weighted mean difference (WMD) and a pooled mean difference with the 95%CI were used to assess the measurement data of included studies. Statistical heterogeneity was tested with the χ2 test. According to forest plots, heterogeneity was not significant, so the fixed effect model was adopted. The significance of the pooled OR was determined by the Z test and statistical significance was considered at P < 0.05.
RESULTS: Data were collected from two studies (353 patients, 142 in the early cholecystectomy group and 211 in the delayed cholecystectomy group) regarding the length of hospital stay [The WMD was -2.87 (95%CI: -3.36--2.39, P < 0.01). Data were collected from four studies (618 patients, 211 in the early cholecystectomy group and 408 in the delayed cholecystectomy group) regarding perioperative complications (OR = 0.94, 95%CI: 0.41-2.12, P > 0.05). Data were collected from four studies (618 patients, 211 in the early cholecystectomy group and 408 in the delayed cholecystectomy group) on the number of patients who underwent ERCP± ES postoperatively (OR = 0.80, 95%CI: 0.45-1.41, P > 0.05).
CONCLUSION: Cholecystectomy offers better protection than ES against further bouts of pancreatitis in patients with gallstone pancreatitis, although ES is an acceptable alternative.
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Abstract
Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to severe acute illness with a significant risk of death. Urgent endoscopic treatment of acute pancreatitis is considered when there is causal evidence of biliary pancreatitis. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.
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Affiliation(s)
- Vincent C Kuo
- Gastroenterology Fellowship, Methodist Dallas Medical Center, 1441 North Beckley Avenue, Dallas, TX 75203, USA
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Abstract
Endoscopy plays an important role in both the diagnosis and the initial management of recurrent acute pancreatitis, as well as the investigation of refractory disease, but it has known limitations and risks. Sound selective use of these therapies, complemented with other lines of investigation such as genetic testing, can dramatically improve frequency of attacks and associated quality of life. Whether endoscopic therapy can reduce progression to chronic pancreatitis, or reduce the risk of malignancy, is debatable, and remains to be proven.
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Sugawa C, Brown KL, Matsubara T, Bachusz R, Ono H, Chino A, Yamasaki T, Lucas CE. The role of endoscopic biliary sphincterotomy for the treatment of type 1 biliary dysfunction (papillary stenosis) with or without biliary stones. Am J Surg 2013; 207:65-9. [PMID: 24070665 DOI: 10.1016/j.amjsurg.2013.04.007] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/20/2012] [Revised: 12/31/2012] [Accepted: 04/24/2013] [Indexed: 01/26/2023]
Abstract
BACKGROUND This study assesses the safety and effectiveness of endoscopic biliary sphincterotomy (ES) in the treatment of papillary stenosis (PS) with and without biliary stones. METHODS The records of all patients who had endoscopic retrograde cholangiopancreatography (2,689 patients) from January 1, 1991, to August 1, 2010, were reviewed. There were 117 patients with PS who had ES. RESULTS All patients had biliary pain, a dilated common bile duct (CBD) with a maximum diameter of 10 to 25 mm, and elevated liver function tests. There were 46 patients who had prior cholecystectomy of whom 20 patients had CBD stones. The remaining 71 patients had no prior biliary surgery; there were no biliary stones in 14 patients. All patients were symptom free after ES with or without CBD stone retrieval. CONCLUSIONS ES is the optimal treatment for PS in patients with or without biliary stones. ES eliminates pain, corrects CBD dilation, and restores LFTs to normal.
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Affiliation(s)
- Choichi Sugawa
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA.
| | - Kristian L Brown
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA
| | - Toshiki Matsubara
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Matsubara Clinic, Ichinomiya, Aichi, Japan
| | - Rebecca Bachusz
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA
| | - Hiromi Ono
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Department of Internal Medicine, Seiwa Memorial Hospital, Sapporo, Japan
| | - Akiko Chino
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Department of Gastroenterology, Cancer Institute Hospital of Japanese Foundation for Cancer Research, Tokyo, Japan
| | - Takuji Yamasaki
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA; Department of Endoscopy, Jikei University School of Medicine, Tokyo, Japan
| | - Charles E Lucas
- Department of Surgery, Detroit Medical Center/Wayne State University, 4201 St Antoine, Suite 6C-UHC, Detroit, MI 48201, USA
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Long-term effectiveness of cholecystectomy and endoscopic sphincterotomy in the management of gallstone pancreatitis. Surg Endosc 2013; 28:127-33. [PMID: 23982647 DOI: 10.1007/s00464-013-3138-6] [Citation(s) in RCA: 22] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/09/2013] [Accepted: 07/22/2013] [Indexed: 12/21/2022]
Abstract
BACKGROUND Gallstone pancreatitis (GSP) is a common condition, accounting for 30-40 % of all pancreatitis cases. All GSP patients should undergo definitive treatment to prevent further attacks. This study aimed to investigate the long-term outcome after definitive treatment in England by cholecystectomy, endoscopic sphincterotomy (ES), or both. METHODS Hospital episode statistics data were used to identify patients admitted for the first time with GSP between January and December 2005. These patients were followed for 18 months to identify those who underwent definitive treatment. Treatment groups then were followed until December 2010 to identify readmissions with a further GSP attack as an emergency or admissions with complications of gallstone disease. RESULTS 5,079 patients admitted with a first bout of GSP between January and December 2005. The in-hospital mortality rate was 7.8 %. Of those who survived the initial attack, 2,511 went on to have a cholecystectomy, 419 had an ES alone, and 496 had ES followed by cholecystectomy. Recurrent pancreatitis after definitive treatment was more common among patients treated with ES (6.7 %) than among those treated with cholecystectomy (4.4 %) or ES followed by cholecystectomy (1.2 %) (p < 0.05). Admissions with other complications attributable to gallstones in patients treated with ES alone were similar to those seen in patients who had received no definitive treatment (12.2 vs. 9.4 %). CONCLUSIONS Cholecystectomy offers better protection than ES against further bouts of pancreatitis in patients with GSP, but ES is an acceptable alternative. Interval cholecystectomy in patients treated initially with ES was the most effective method of preventing further pancreatitis, and the patients who underwent treatment by ES alone remained at risk of readmission with gallstone-related problems. Patients who have undergone ES and are fit for surgery should have a cholecystectomy.
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Duncan CB, Riall TS. Evidence-based current surgical practice: calculous gallbladder disease. J Gastrointest Surg 2012; 16:2011-25. [PMID: 22986769 PMCID: PMC3496004 DOI: 10.1007/s11605-012-2024-1] [Citation(s) in RCA: 82] [Impact Index Per Article: 6.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/01/2012] [Accepted: 08/15/2012] [Indexed: 01/31/2023]
Abstract
BACKGROUND Gallbladder disease is common and, if managed incorrectly, can lead to high rates of morbidity, mortality, and extraneous costs. The most common complications of gallstones include biliary colic, acute cholecystitis, common bile duct stones, and gallstone pancreatitis. Ultrasound is the initial imaging modality of choice. Additional diagnostic and therapeutic studies including computed tomography, magnetic resonance imaging, magnetic resonance cholangiopancreatography, endoscopic ultrasound, and endoscopic retrograde cholangiopancreatography are not routinely required but may play a role in specific situations. DISCUSSION Biliary colic and acute cholecystitis are best treated with early laparoscopic cholecystectomy. Patients with common bile duct stones should be managed with cholecystectomy, either after or concurrent with endoscopic or surgical relief of obstruction and clearance of stones from the bile duct. Mild gallstone pancreatitis should be treated with cholecystectomy during the initial hospitalization to prevent recurrence. Emerging techniques for cholecystectomy include single-incision laparoscopic surgery and natural orifice transluminal endoscopic surgery. Early results in highly selected patients demonstrate the safety of these techniques. The management of complications of the gallbladder should be timely and evidence-based, and choice of procedures, particularly for common bile duct stones, is largely influenced by facility and surgeon factors.
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Affiliation(s)
- Casey B Duncan
- Department of Surgery, The University of Texas Medical Branch, 301 University Boulevard, Galveston, TX 77555-0541, USA
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El-Dhuwaib Y, Deakin M, David GG, Durkin D, Corless DJ, Slavin JP. Definitive management of gallstone pancreatitis in England. Ann R Coll Surg Engl 2012; 94:402-6. [PMID: 22943329 PMCID: PMC3954320 DOI: 10.1308/003588412x13171221591934] [Citation(s) in RCA: 42] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 02/09/2012] [Indexed: 12/27/2022] Open
Abstract
INTRODUCTION The aim of this study was to investigate whether definitive treatment of gallstone pancreatitis (GSP) by either cholecystectomy or endoscopic sphincterotomy in England conforms with British Society of Gastroenterology (BSG) guidelines and to validate these guidelines. METHODS Hospital Episode Statistics data were used to identify patients admitted for the first time with GSP between April 2007 and April 2008. These patients were followed until April 2009 to identify any who underwent definitive treatment or were readmitted with a further bout of GSP as an emergency. RESULTS A total of 5,454 patients were admitted with GSP between April 2007 and April 2008, of whom 1,866 (34.2%) underwent definitive treatment according to BSG guidelines, 1,471 on the index admission. Patients who underwent a cholecystectomy during the index admission were less likely to be readmitted with a further bout of GSP (1.7%) than those who underwent endoscopic sphincterotomy alone (5.3%) or those who did not undergo any form of definitive treatment (13.2%). Of those patients who did not undergo definitive treatment before discharge, 2,239 received definitive treatment following discharge but only 395 (17.6%) of these had this within 2 weeks. Of the 505 patients who did not undergo definitive treatment on the index admission and who were readmitted as an emergency with GSP, 154 (30.5%) were admitted during the 2 weeks immediately following discharge. CONCLUSIONS Following an attack of mild GSP, cholecystectomy should be offered to all patients prior to discharge. If patients are not fit for surgery, an endoscopic sphincterotomy should be performed as definitive treatment.
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Affiliation(s)
| | - M Deakin
- University Hospital of North Staffordshire NHS Trust,UK
| | - GG David
- Mid Cheshire Hospitals NHS Foundation Trust,UK
| | - D Durkin
- University Hospital of North Staffordshire NHS Trust,UK
| | - DJ Corless
- Mid Cheshire Hospitals NHS Foundation Trust,UK
| | - JP Slavin
- Mid Cheshire Hospitals NHS Foundation Trust,UK
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Abstract
OBJECTIVES To determine the risk of recurrent biliary events in the period after mild biliary pancreatitis but before interval cholecystectomy and to determine the safety of cholecystectomy during the index admission. BACKGROUND Although current guidelines recommend performing cholecystectomy early after mild biliary pancreatitis, consensus on the definition of early (ie, during index admission or within the first weeks after hospital discharge) is lacking. METHODS We performed a systematic search in PubMed, Embase, and Cochrane for studies published from January 1992 to July 2010. Included were cohort studies of patients with mild biliary pancreatitis reporting on the timing of cholecystectomy, number of readmissions for recurrent biliary events before cholecystectomy, operative complications (eg, bile duct injury, bleeding), and mortality. Study quality and risks of bias were assessed. RESULTS After screening 2413 studies, 8 cohort studies and 1 randomized trial describing 998 patients were included. Cholecystectomy was performed during index admission in 483 patients (48%) without any reported readmissions. Interval cholecystectomy was performed in 515 patients (52%) after 40 days (median; interquartile range: 19-58 days). Before interval cholecystectomy, 95 patients (18%) were readmitted for recurrent biliary events (0% vs 18%, P < 0.0001). These included recurrent biliary pancreatitis (n = 43, 8%), acute cholecystitis (n = 17), and biliary colics (n = 35). Patients who had an endoscopic retrograde cholangiopancreatography had fewer recurrent biliary events (10% vs 24%, P = 0.001), especially less recurrent biliary pancreatitis (1% vs 9%). There were no differences in operative complications, conversion rate (7%), and mortality (0%) between index and interval cholecystectomy. Because baseline characteristics were only reported in 26% of patients, study populations could not be compared. CONCLUSIONS Interval cholecystectomy after mild biliary pancreatitis is associated with a high risk of readmission for recurrent biliary events, especially recurrent biliary pancreatitis. Cholecystectomy during index admission for mild biliary pancreatitis appears safe, but selection bias could not be excluded.
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Knott EM, Gasior AC, Bikhchandani J, Cunningham JP, St. Peter SD. Surgical Management of Gallstone Pancreatitis in Children. J Laparoendosc Adv Surg Tech A 2012; 22:501-4. [DOI: 10.1089/lap.2011.0514] [Citation(s) in RCA: 8] [Impact Index Per Article: 0.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/08/2023] Open
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Early cholecystectomy and ERCP are associated with reduced readmissions for acute biliary pancreatitis: a nationwide, population-based study. Gastrointest Endosc 2012; 75:47-55. [PMID: 22100300 DOI: 10.1016/j.gie.2011.08.028] [Citation(s) in RCA: 41] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/22/2011] [Accepted: 08/14/2011] [Indexed: 02/08/2023]
Abstract
BACKGROUND Cholecystectomy is recommended during hospitalizations for acute biliary pancreatitis (ABP). OBJECTIVE We sought to assess the population-based effectiveness of index cholecystectomy by using nationwide data. DESIGN Retrospective, cohort study. SETTING All acute-care hospitals in Canada from 2007 to 2010. PATIENTS This study involved patients admitted for ABP in the Canadian Institutes for Health Information hospital discharge database. INTERVENTION Cholecystectomy and therapeutic ERCP during the index admission. MAIN OUTCOME MEASUREMENTS Rate of hospital readmissions for ABP. RESULTS Among 5646 patients with ABP, 32% underwent cholecystectomy and 22% ERCP during the index admissions. Patients admitted to hospitals in the highest quartile for cholecystectomy volume were more than 10-fold likely to undergo cholecystectomy during the index admission (adjusted odds ratio 11.0; 95% confidence interval [CI], 7.4-16.5). The 12-month readmission rate for ABP was lower with cholecystectomy (5.6% vs 14.0%; P < .0001) and therapeutic ERCP (5.1% vs 13.1%; P < .0001). After multivariate adjustment, lower readmission rates were independently associated with both cholecystectomy (adjusted hazard ratio [HR] 0.39; 95% CI, 0.32-0.48) and ERCP (adjusted HR 0.37; 95% CI, 0.29-0.50). After excluding early readmissions (within 28 days of discharge), the adjusted HR for cholecystectomy was 0.43 (95% CI, 0.34-0.57). The admitting hospital's cholecystectomy volume was inversely associated with 12-month readmission rates for ABP (quartile 1, 15.9%; quartile 2, 13.9%; quartile 3, 11.3%; quartile 4, 10.0%; P < .001). LIMITATIONS The study was based on hospital administrative data. CONCLUSION Cholecystectomy and ERCP during the index admission were associated with reduced readmission rates for ABP, providing population-based evidence to support consensus guidelines that recommend early biliary intervention.
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Somasekar K, Foulkes R, Morris-Stiff G, Hassn A. Acute pancreatitis in the elderly - Can we perform better? Surgeon 2011; 9:305-8. [DOI: 10.1016/j.surge.2010.11.001] [Citation(s) in RCA: 23] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/12/2010] [Accepted: 11/02/2010] [Indexed: 01/08/2023]
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Bakker OJ, van Santvoort HC, Hagenaars JC, Besselink MG, Bollen TL, Gooszen HG, Schaapherder AF. Timing of cholecystectomy after mild biliary pancreatitis. Br J Surg 2011; 98:1446-54. [DOI: 10.1002/bjs.7587] [Citation(s) in RCA: 59] [Impact Index Per Article: 4.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Accepted: 04/04/2011] [Indexed: 12/21/2022]
Abstract
Abstract
Background
The aim of the study was to evaluate recurrent biliary events as a consequence of delay in cholecystectomy following mild biliary pancreatitis.
Methods
Between 2004 and 2007, patients with acute pancreatitis were registered prospectively in 15 Dutch hospitals. Patients with mild biliary pancreatitis were candidates for cholecystectomy. Recurrent biliary events requiring admission before and after cholecystectomy, and after endoscopic sphincterotomy (ES), were evaluated.
Results
Of 308 patients with mild biliary pancreatitis, 267 were candidates for cholecystectomy. Eighteen patients underwent cholecystectomy during the initial admission, leaving 249 potential candidates for cholecystectomy after discharge. Cholecystectomy was performed after a median of 6 weeks in 188 patients (75·5 per cent). Before cholecystectomy, 34 patients (13·7 per cent) were readmitted for biliary events, including 24 with recurrent biliary pancreatitis. ES was performed in 108 patients during the initial admission. Eight (7·4 per cent) of these patients suffered from biliary events after ES and before cholecystectomy, compared with 26 (18·4 per cent) of 141 patients who did not have ES (risk ratio 0·51, 95 per cent confidence interval 0·27 to 0·94; P = 0·015). Following cholecystectomy, eight (3·9 per cent) of 206 patients developed biliary events after a median of 31 weeks. Only 142 (53·2 per cent) of 267 patients were treated in accordance with the Dutch guideline, which recommends cholecystectomy or ES during the index admission or within 3 weeks thereafter.
Conclusion
A delay in cholecystectomy after mild biliary pancreatitis carries a substantial risk of recurrent biliary events. ES reduces the risk of recurrent pancreatitis but not of other biliary events.
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Affiliation(s)
| | - O J Bakker
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - H C van Santvoort
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - J C Hagenaars
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - M G Besselink
- Department of Surgery, University Medical Centre Utrecht, Utrecht, The Netherlands
| | - T L Bollen
- Department of Radiology, St Antonius Hospital, Nieuwegein, The Netherlands
| | - H G Gooszen
- Department of Operation Room/Evidence Based Surgery, Radboud University Nijmegen Medical Centre, Nijmegen, The Netherlands
| | - A F Schaapherder
- Department of Surgery, Leiden University Medical Centre, Leiden, The Netherlands
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Sheffield KM, Ramos KE, Djukom CD, Jimenez CJ, Mileski WJ, Kimbrough TD, Townsend CM, Riall TS. Implementation of a critical pathway for complicated gallstone disease: translation of population-based data into clinical practice. J Am Coll Surg 2011; 212:835-43. [PMID: 21398156 DOI: 10.1016/j.jamcollsurg.2010.12.047] [Citation(s) in RCA: 21] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/15/2010] [Revised: 12/17/2010] [Accepted: 12/21/2010] [Indexed: 01/01/2023]
Abstract
BACKGROUND Evidence-based guidelines recommend cholecystectomy during initial hospitalization for complicated gallstone disease. Previous studies and quality initiative data from our institution demonstrated that only 40% to 75% of patients underwent cholecystectomy on index admission. STUDY DESIGN In January 2009, we implemented a critical pathway to improve cholecystectomy rates for all patients emergently admitted for acute cholecystitis, mild gallstone pancreatitis, or common bile duct stones. We compared cholecystectomy rates during initial hospitalization, time to cholecystectomy, length of initial stay, and readmission rates in prepathway (January 2005 to February 2008) and postpathway patients (January 2009 to May 2010). RESULTS Demographic and clinical characteristics were similar between prepathway (n = 455) and postpathway patients (n = 112). Cholecystectomy rates during initial hospitalization increased from 48% to 78% after pathway implementation (p < 0.0001). There were no differences in operative mortality or operative complications between the 2 groups. For patients undergoing cholecystectomy on initial hospitalization, the mean length of stay decreased after pathway implementation (7.1 days to 4.5 days; p < 0.0001), primarily due to a decrease in the time from admission to cholecystectomy (4.1 days to 2.1 days; p < 0.0001). Thirty-three percent of prepathway and 10% of postpathway patients required readmission for gallstone-related problems or operative complications (p < 0.0001), and each readmission generated an average of $19,000 in additional charges. CONCLUSIONS Implementation of a multidisciplinary critical pathway improved cholecystectomy rates on initial hospitalization and lowered costs by shortening length of stay and markedly decreasing readmission rates for gallstone-related problems. Broader implementation of similar pathways offers the potential to translate evidence-based guidelines into clinical practice and minimize the cost of medical care.
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Affiliation(s)
- Kristin M Sheffield
- Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA.
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Wilson CT, de Moya MA. Cholecystectomy for Acute Gallstone Pancreatitis: Early Vs Delayed Approach. Scand J Surg 2010; 99:81-5. [DOI: 10.1177/145749691009900207] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 01/14/2023]
Abstract
Background and Aims: The management of gallstone pancreatitis, in particular timing of cholecystectomy, has evolved substantially over the last decade. The trend has been toward earlier cholecystectomy. We review current literature regarding the timing of cholecystectomy in the context of gallstone pancreatitis. Materials and Methods: The authors performed a literature search in PubMed for relevant articles in the English language with greatest weight given to prospective trials compared to observational studies and previous reviews. Results: The literature search yielded 59 articles discussing cholecystectomy in the context of gallstone pancreatitis. Most were retrospective studies or reviews, but there were nine prospective observational studies and two randomized control trials. For mild gallstone pancreatitis, laparoscopic cholecystectomy within 48 hours of presentation (without normalization of pancreatic enzymes or absence of abdominal pain) has been shown to shorten hospital stay without increased morbidity or mortality. Routine preoperative ERCP is unnecessary for patients with mild disease. For more severe disease, timing of cholecystectomy is governed by clinical status. Interval cholecystectomy (>2 weeks after index admission) can be safely done with low risk of recurrence if the patient has had ERCP and sphincterotomy at index admission. Conclusion: Patients with mild gallstone pancreatitis should have cholecystectomy during index admission within 48 hours of arrival, but patients with more severe disease will require cholecystectomy at a later time, depending on the clinical circumstances. Sphincterotomy should be done as soon as possible if cholecystectomy is not feasible early in course.
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Affiliation(s)
- C. T. Wilson
- Department of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, MA, U.S.A
| | - M. A. de Moya
- Department of Trauma, Emergency Surgery, and Critical Care, Massachusetts General Hospital, Boston, MA, U.S.A
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30
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Wada K, Takada T, Hirata K, Mayumi T, Yoshida M, Yokoe M, Kiriyama S, Hirota M, Kimura Y, Takeda K, Arata S, Hirota M, Sekimoto M, Isaji S, Takeyama Y, Gabata T, Kitamura N, Amano H. Treatment strategy for acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2010; 17:79-86. [PMID: 20012325 DOI: 10.1007/s00534-009-0218-z] [Citation(s) in RCA: 27] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/16/2022]
Abstract
When a diagnosis of acute pancreatitis (AP) is made, fundamental medical treatment consisting of fasting, intravenous (IV) fluid replacement, and analgesics with a close monitoring of vital signs should be immediately started. In parallel with fundamental medical treatment, assessment of severity based on clinical signs, blood test, urinalysis and imaging tests should be performed to determine the way of treatment for each patient. A repeat evaluation of severity is important since the condition is unstable especially in the early stage of AP. At the time of initial diagnosis, the etiology should be investigated by means of blood test, urinalysis and diagnostic imaging. If a biliary pancreatitis accompanied with acute cholangitis or biliary stasis is diagnosed or suspected, an early endoscopic retrograde cholangiopancreatography with or without endoscopic sphincterotomy (ERCP/ES) is recommended in addition to the fundamental medical treatment. In mild cases, the fundamental medical treatment should be continued until clinical symptom is subsided with normal laboratory data. In cases with severe acute pancreatitis (SAP) referral should be considered to medical centers experienced in the treatment of SAP, and intensive care is recommended for preventing both organ failures and infectious complications. Hemodynamic stabilization with vigorous fluid resuscitation, respiratory support and antibiotics are the major parts of intensive care in the early period of SAP. Continuous hemodiafiltration (CHDF) and continuous regional arterial infusion (CRAI) of protease inhibitor and/or antibiotics may be effective to improve pathophysiology of AP especially in the early stage of the disease. In the late stage of AP, infectious complications are critical. If an infectious complication is suspected based on clinical signs, blood test and imaging, a fine needle aspiration (FNA) is recommended to establish a diagnosis. The accuracy of FNA is reported to be 89 ~ 100%. For patients with sterile pancreatitis, non-surgical treatment should be indicated. For patients with infected pancreatic necrosis, therapeutic intervention either by percutaneous, endoscopic, laparoscopic or surgical approach are indicated. The most preferred surgical intervention is necrosectomy, however, non-surgical treatment with antibiotics is still the treatment of choice if the general condition is stable. Necrosectomy should be performed as late as possible. For patients with pancreatic abscess, drainage is recommended.
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Affiliation(s)
- Keita Wada
- Department of Surgery, Teikyo University School of Medicine, 2-11-1, Kaga-cho, Itabashi, Tokyo, 173, Japan.
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Abstract
OBJECTIVE We explored whether admission volumes for cholecystectomy (CCY) and pancreatitis were associated with receiving CCY after hospitalization for acute biliary pancreatitis (ABP). METHODS We identified admissions for ABP in the Nationwide Inpatient Sample between 1998 and 2003. We used multivariate analysis to assess the association between likelihood of CCY and hospital volumes of CCY, pancreatitis, and endoscopic retrograde cholangiopancreatography (ERCP). RESULTS The overall rate of CCY for ABP was 50%. After adjustment for confounders, the likelihood of CCY increased with every quartile of CCY volume relative to the bottom quartile (adjusted odds ratios of 4.36, 7.92, and 12.51 for quartiles 2, 3, and 4, respectively, P < 0.0001). Pancreatitis volume was inversely correlated with likelihood of CCY (adjusted odds ratios of 0.72, 0.62, and 0.48 for quartiles 2, 3, and 4, respectively, vs bottom quartile, P < 0.01). Admissions to hospitals in the top quartile for ERCP volume (>35 ERCPs/yr) had 15% lower odds of CCY than the lowest quartile. Patients from rural areas and with lower income were disproportionately admitted to hospitals with lower CCY volumes. CONCLUSIONS US hospitals are not achieving targets for CCY after ABP as set by national and international guidelines. Centers with smaller CCY volumes are the least adherent to recommendations for CCY possibly because of hospital-level resource limitations.
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Gallstone-induced acute pancreatitis. JOURNAL OF HEPATO-BILIARY-PANCREATIC SCIENCES 2009; 17:60-9. [PMID: 20012326 DOI: 10.1007/s00534-009-0217-0] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Received: 08/01/2009] [Accepted: 09/01/2009] [Indexed: 12/13/2022]
Abstract
In the care of acute pancreatitis, a prompt search for the etiologic condition of the disease should be conducted. A differentiation of gallstone-induced acute pancreatitis should be given top priority in its etiologic diagnosis because it is related to the decision of treatment policy. Examinations necessary for diagnosing gallstone-induced acute pancreatitis include blood tests and ultrasonography. Early ERCP/ES should be performed in patients with gallstone-induced acute pancreatitis if a complication of cholangitis and a prolonged passage disorder of the biliary tract are suspected. The treatment for bile duct stones with the use of ERCP/ES alone is not recommended in cases of gallstone-induced pancreatitis with gallbladder stones. Cholecystectomy for gallstone-induced acute pancreatitis should be performed using a laparoscopic procedure as the first option as soon as the disease has subsided.
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Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy. Surg Endosc 2009; 23:950-6. [PMID: 19266236 DOI: 10.1007/s00464-009-0339-0] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/12/2008] [Revised: 12/19/2008] [Accepted: 01/01/2009] [Indexed: 10/21/2022]
Abstract
BACKGROUND Recurrent attacks of acute biliary pancreatitis (RABP) are prevented by (laparoscopic) cholecystectomy. Since the introduction of endoscopic retrograde cholangiopancreaticography (ERCP), several series have described a similar reduction of RABP after endoscopic sphincterotomy (ES). This report discusses the different treatment options for preventing RABP including conservative treatment, cholecystectomy, ES, and combinations of these options as well as their respective timing. METHODS A search in PubMed for observational studies and clinical (comparative) trials published in the English language was performed on the subject of recurrent acute biliary pancreatitis and other gallstone complications after an initial attack of acute pancreatitis. RESULT Cholecystectomy and ES both are superior to conservative treatment in reducing the incidence of RABP. Cholecystectomy provides additional protection for gallstone-related complications and mortality. Observational studies indicate that cholecystectomy combined with ES is the most effective treatment for reducing the incidence of RABP attacks. CONCLUSION From the literature data it can be concluded that ES is as effective in reducing RABP as cholecystectomy but inferior in reducing mortality and overall morbidity. The combination of ES and cholecystectomy seems superior to either of the treatment methods alone. A prospective randomized clinical trial comparing ES plus cholecystectomy with cholecystectomy alone is needed.
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34
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Abstract
OBJECTIVES Both endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic ultrasonography (EUS) are commonly performed in the evaluation of idiopathic pancreatitis. However, comparative trials of these modalities are lacking, and thus the ideal endoscopic diagnostic strategy to evaluate idiopathic pancreatitis remains unknown. METHODS A decision analysis model of patients with 2 attacks of idiopathic pancreatitis with gallbladder in situ was constructed using TreeAge software. We analyzed cost and overall diagnostic ability of 3 strategies, namely, EUS, ERCP with manometry and bile aspiration, and laparoscopic cholecystectomy. RESULTS Using the base case analysis, initial EUS was the preferred initial modality for the diagnosis. The expected cost for initial EUS was $4469 compared with $4615 for ERCP and $6268 for laparoscopic cholecystectomy. For cholecystectomy to be the preferred strategy, the total cost would need to be less than $1314, well below any realistic cost estimate. If the prevalence of microlithiasis/sludge was greater than 80%, then cholecystectomy would be preferred, whereas ERCP would be preferred with a prevalence of less than 41%. CONCLUSIONS This cost minimization study identifies EUS as the least costly initial test for the diagnostic evaluation of patients with idiopathic pancreatitis with gallbladder in situ.
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Affiliation(s)
- Charles Mel Wilcox
- Department of Medicine, Division of Gastroenterology and Hepatology, School of Public Health, University of Alabama at Birmingham, Birmingham, AL 35294-0007, USA.
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35
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Hasibeder WR, Torgersen C, Rieger M, Dünser M. Critical Care of the Patient with Acute Pancreatitis. Anaesth Intensive Care 2009; 37:190-206. [DOI: 10.1177/0310057x0903700206] [Citation(s) in RCA: 29] [Impact Index Per Article: 1.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/17/2022]
Abstract
Acute pancreatitis is an inflammatory process of the pancreas with variable involvement of regional tissues and remote organs. This review gives a comprehensive overview of the aetiology, pathophysiology, diagnosis and therapy of acute pancreatitis relevant to the intensivist. Recent international guidelines on the management of acute pancreatitis are summarised. Eighty percent of acute pancreatitis episodes are related either to gallstones or to alcohol abuse. Independent of its aetiology, the pathophysiologic hallmark of acute pancreatitis is the premature activation of trypsin, which leads to massive pancreas inflammation, systemic overproduction of pro-inflammatory mediators and ultimately remote organ dysfunction. All guidelines agree that the diagnosis of acute pancreatitis should include clinical symptoms, increased serum amylase or lipase levels and/or characteristic findings on computed tomography. Endoscopic retrograde cholangiopancreatography is recommended as a causative therapy in patients with acute cholangitis or a strong suspicion of gallstones. All guidelines underline the importance of vigorous fluid resuscitation and supplemental oxygen therapy and prefer enteral over parenteral nutrition, with the majority favouring the nasojejunal route. In view of lacking scientific evidence, antibiotic prophylaxis to prevent infection of pancreatic necroses is discouraged by most guidelines. Computed tomography-guided fine needle aspiration is the technique of choice to differentiate between sterile and infected pancreas necrosis. While sterile pancreatic necrosis should be managed conservatively, infected pancreatic necrosis requires debridement and drainage supplemented by antibiotic therapy. Surgical necrosectomy is the traditional approach, but less invasive techniques (retroperitoneal or laparoscopic necrosectomy, computed tomography-guided percutaneous catheter drainage) may be equally effective.
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Affiliation(s)
- W. R. Hasibeder
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Department of Anaesthesiology and Critical Care Medicine, Krankenhaus der Barmherzigen Schwestern, Ried im Innkreis
| | - C. Torgersen
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Anaesthetist
| | - M. Rieger
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Department of Radiology
| | - M. Dünser
- Department of Anaesthesiology and Critical Care Medicine, Innsbruck Medical University, Innsbruck, Austria
- Anaesthetist
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36
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Nebiker CA, Frey DM, Hamel CT, Oertli D, Kettelhack C. Early versus delayed cholecystectomy in patients with biliary acute pancreatitis. Surgery 2009; 145:260-4. [PMID: 19231577 DOI: 10.1016/j.surg.2008.10.012] [Citation(s) in RCA: 42] [Impact Index Per Article: 2.6] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2008] [Accepted: 10/01/2008] [Indexed: 12/16/2022]
Abstract
BACKGROUND In patients with biliary acute pancreatitis (AP), cholecystectomy is mandatory to prevent further biliary events, but timing of cholecystectomy remains a subject of ongoing debate. The objective of the present, retrospective study was to compare the outcomes of early (within 2 weeks after onset of disease) versus delayed cholecystectomy in patients with biliary AP. METHODS Between January 2000 and December 2005, 112 patients underwent cholecystectomy because of biliary AP. Thirteen patients were excluded from analysis because of necrotizing pancreatitis on the initial computed tomography. Thirty-two were operated within 14 days (group A) and 67 after a longer time period (group B). The primary end point of the study was the rate of biliary complications before cholecystectomy. RESULTS There were no differences regarding conversion rates to open surgery (6% vs 3%; P = .59), local (3% vs 4%; P = 1.00), or systemic complications (0% vs 3%; P = 1.00), and mean postoperative stay (4.7 vs 5.7 days; P = .40). Nevertheless, a greater rate of recurrent biliary pancreatitis was found in the group undergoing cholecystectomy later (0% vs 13%; P < .03). CONCLUSION The timing of cholecystectomy seems to have no clinically relevant effect on local or systemic complications, but delaying cholecystectomy is associated with an increase of biliary complications in patients with non-necrotizing biliary AP.
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37
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Complications of Gallstones: The Mirizzi Syndrome, Gallstone Ileus, Gallstone Pancreatitis, Complications of “Lost” Gallstones. Surg Clin North Am 2008; 88:1345-68, x. [PMID: 18992599 DOI: 10.1016/j.suc.2008.07.011] [Citation(s) in RCA: 47] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
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Ito K, Ito H, Whang EE. Timing of cholecystectomy for biliary pancreatitis: do the data support current guidelines? J Gastrointest Surg 2008; 12:2164-70. [PMID: 18636298 DOI: 10.1007/s11605-008-0603-y] [Citation(s) in RCA: 69] [Impact Index Per Article: 4.1] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/29/2008] [Accepted: 06/25/2008] [Indexed: 02/06/2023]
Abstract
BACKGROUND Current guidelines suggest that cholecystectomy be performed within 2 weeks after discharge following an episode of biliary pancreatitis. We hypothesized that a high incidence of gallstone-related events is present within 2 weeks after discharge prior to cholecystectomy. METHODS Two hundred eighty-one patients who underwent cholecystectomy for biliary pancreatitis (January 1999-December 2005) were categorized into one of two groups: group A patients underwent cholecystectomy during index admission (n = 162), and group B patients underwent cholecystectomy following discharge from index admission (n = 119). RESULTS Groups were comparable in demographics, comorbidities, and disease severity. Thirty-nine (32.8%) group B patients experienced pre-cholecystectomy gallstone-related events (including 16 cases of recurrent pancreatitis) after discharge. Recurrences (31.3%) occurred within 2 weeks after discharge. Endoscopic sphincterotomy protected against preoperative recurrent pancreatitis but was associated with a higher incidence of other gallstone-related events. Median total length of hospital stay was greater for group B than for group A [7 (range, 2-37) days vs. 5 (1-45) days, respectively, p = 0.00]. CONCLUSION Current guidelines suggesting the appropriateness of waiting up to 2 weeks for cholecystectomy for biliary pancreatitis may place patients at unacceptably high risk for recurrence. Endoscopic sphincterotomy does not eliminate the risk of gallstone-related events.
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Affiliation(s)
- Kaori Ito
- Department of Surgery, Brigham and Women's Hospital, Harvard Medical School, 75 Francis Street, Boston, MA 02115, USA
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39
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Nguyen GC, Tuskey A, Jagannath SB. Racial disparities in cholecystectomy rates during hospitalizations for acute gallstone pancreatitis: a national survey. Am J Gastroenterol 2008; 103:2301-7. [PMID: 18844616 DOI: 10.1111/j.1572-0241.2008.01949.x] [Citation(s) in RCA: 48] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/11/2022]
Abstract
BACKGROUND Practice guidelines advocate performing cholecystectomy for acute gallstone pancreatitis during the same hospitalization stay. Our objectives were to determine nationwide rates of adherence to these guidelines in the United States and whether this varied with race and ethnicity. METHODS We queried the Nationwide Inpatient Sample (NIS) to identify admissions for acute gallstone pancreatitis between 1998 and 2003. We calculated overall and race-specific proportions of patients who underwent cholecystectomy or endoscopic retrograde cholangiopancreatography (ERCP) prior to discharge. We used multivariate analysis to determine racial effects while adjusting for age, comorbidity, health insurance payer, and hospital factors. RESULTS The overall rate of cholecystectomy was 51% and that of either cholecystectomy or ERCP was 62%. Cholecystectomy rates were lower among African Americans (AAs) and Asians compared to Whites (44% and 43%, respectively, vs 50%, P < 0.001). After multivariate adjustment, the odds of cholecystectomy was lower in AAs (OR 0.68, 95% CI 0.63-0.73) and Asians/Pacific Islanders (OR 0.75, 95% CI 0.65-0.87) relative to Whites, while rates were modestly higher among Hispanics (OR 1.12, 95% CI 1.03-1.22). AAs were less likely to receive ERCP than Whites (OR 0.71, 95% CI 0.65-0.78). In contrast, Asians/Pacific Islanders (OR 1.40, 95% CI 1.16-1.69) and Hispanics (OR 1.19, 95% CI 1.09-1.29) were more likely to receive ERCP than Whites. CONCLUSIONS Despite practice guidelines, about only half of admissions for gallstone pancreatitis receive cholecystectomy during the same hospitalization, and cholecystectomy rates vary substantially by race. These findings raise concerns regarding suboptimal healthcare delivery.
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Affiliation(s)
- Geoffrey C Nguyen
- Mount Sinai Hospital, University of Toronto Faculty of Medicine, Toronto, Ontario, Canada
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40
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Canlas KR, Branch MS. Role of endoscopic retrograde cholangiopancreatography in acute pancreatitis. World J Gastroenterol 2008. [PMID: 18081218 DOI: 10.3748/wjg.13.6314] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.2] [Reference Citation Analysis] [Abstract] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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Affiliation(s)
- Karen R Canlas
- Division of Gastroenterology and Hepatology, Duke University Medical Center, DUMC Box 3662, Durham, NC 27710, United States
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41
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Terui K, Yoshida H, Kouchi K, Hishiki T, Saito T, Mitsunaga T, Takenouchi A, Tsuyuguchi T, Yamaguchi T, Ohnuma N. Endoscopic sphincterotomy is a useful preoperative management for refractory pancreatitis associated with pancreaticobiliary maljunction. J Pediatr Surg 2008; 43:495-499. [PMID: 18358288 DOI: 10.1016/j.jpedsurg.2007.10.071] [Citation(s) in RCA: 26] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/16/2023]
Abstract
BACKGROUND Pancreatitis associated with pancreaticobiliary maljunction (PBM) is commonly treated nonoperatively before surgery. It is, however, sometimes uncontrollable, and little has been reported about the management. METHODS Focusing on the preoperative management, we reviewed clinical courses of 4 PBM cases (ages 1 to 7 years old). Each had pancreatitis that was totally resistant to medical treatment and was applied endoscopic sphincterotomy (ES). RESULTS The first case underwent percutaneous transhepatic catheter drainage (PTCD) primarily. In spite of daily lavage using the drainage tube for a week, plugs located in the common channel were not removed, and clinical findings were not improved. Therefore, ES followed by removal of protein plugs was performed to improve pancreatitis dramatically. Through this experience, 3 subsequent cases with refractory pancreatitis all underwent successful ES primarily soon after the medical treatments turned out to be ineffective. In all 4 cases, protein plugs were impacted in common channels, and ES could successfully remove the plugs that were impossible to remove by using PTCD. Improved preoperative pancreaticobiliary decompression by ES shortens the duration of recalcitrant acute pancreatitis associated with PBM allowing for a subsequent safe operation. CONCLUSIONS Endoscopic sphincterotomy is one of the useful preoperative managements for refractory pancreatitis associated with PBM.
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Affiliation(s)
- Keita Terui
- Department of Pediatric Surgery, Graduate School of Medicine, Chiba University, Chiba 260-8677, Japan.
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42
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Abstract
Endoscopic retrograde cholangiopancreatography (ERCP) is a useful tool in the evaluation and management of acute pancreatitis. This review will focus on the role of ERCP in specific causes of acute pancreatitis, including microlithiasis and gallstone disease, pancreas divisum, Sphincter of Oddi dysfunction, tumors of the pancreaticobiliary tract, pancreatic pseudocysts, and pancreatic duct injury. Indications for endoscopic techniques such as biliary and pancreatic sphincterotomy, stenting, stricture dilation, treatment of duct leaks, drainage of fluid collections and stone extraction will also be discussed in this review. With the advent of less invasive and safer diagnostic modalities including endoscopic ultrasound (EUS) and magnetic retrograde cholangiopancreatography (MRCP), ERCP is appropriately becoming a therapeutic rather than diagnostic tool in the management of acute pancreatitis and its complications.
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43
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Teoh AYB, Poon MCM, Leong HT. Role of prophylactic endoscopic sphincterotomy in patients with acute biliary pancreatitis due to transient common bile duct obstruction. J Gastroenterol Hepatol 2007; 22:1415-8. [PMID: 17645462 DOI: 10.1111/j.1440-1746.2007.05030.x] [Citation(s) in RCA: 5] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/26/2023]
Abstract
BACKGROUND AND AIM The role of prophylactic endoscopic sphincterotomy in patients with transient common bile duct obstruction is controversial. The aim of this study was to assess the value of performing prophylactic endoscopic sphincterotomy in patients suffering from acute biliary pancreatitis and absent common bile duct stones on endoscopic retrograde cholangiopancreatography (ERCP). METHODS Hospital notes of patients admitted to our unit with a diagnosis of acute pancreatitis from January 2000 to January 2005 were reviewed. Endoscopic sphincterotomy was performed when patients were deemed unfit for cholecystectomy, suffering from a severe attack of acute pancreatitis and/or showing evidence of transient common bile duct obstruction. The outcomes of patients with and without endoscopic sphincterotomy were compared. RESULTS A total of 427 patients were admitted with a diagnosis of acute pancreatitis during the study period. Eighty-eight patients with absent common bile duct stones on ERCP were identified. Endoscopic sphincterotomy was performed in 71 patients and not performed in 17 patients. There was no significant difference in recurrent pancreatitis rates (1.4% vs 5.8%, P = 0.35), recurrent biliary complication rates (5.6% vs 5.9%, P = 1) or mortality rates (5.8% vs 1.5%, P = 0.35). The time to recurrent complications (38.4 days vs 41.0 days, P = 0.38) was not significantly different between the two groups. There was no ERCP-related morbidity or mortality. CONCLUSION Prophylactic endoscopic sphincterotomy is not recommended in patients with transient common bile duct obstruction or as an option to cholecystectomy in elderly patients. Early cholecystectomy should be performed.
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Affiliation(s)
- Anthony Y B Teoh
- Department of Surgery, North District Hospital, Sheung Shui, Hong Kong SAR, China.
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Affiliation(s)
- Chris E Forsmark
- Division of Gastroenterology, Hepatology, and Nutrition, University of Florida, Gainesville, Florida, USA
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Abstract
Acute pancreatitis represents numerous unique challenges to the practicing digestive disease specialist. Clinical presentations of acute pancreatitis vary from trivial pain to devastating acute illness with a significant risk of death. This article focuses on the diagnosis and endoscopic treatment of acute biliary pancreatitis.
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Affiliation(s)
- Paul R Tarnasky
- Digestive Health Associates of Texas, Methodist Dallas Medical Center, 221 West Colorado Boulevard, Suite #630, Pavilion II, Dallas, TX 75208, USA.
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Jenkins JT, Williamson BWA. Prospective study to develop an algorithm for investigation by endoscopic retrograde cholangiopancreatography or magnetic resonance cholangiopancreatography. ANZ J Surg 2007; 76:977-80. [PMID: 17054546 DOI: 10.1111/j.1445-2197.2006.03914.x] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/29/2022]
Abstract
BACKGROUND Identifying cost-efficient and patient-friendly pathways for those who present with suspected pancreatico-biliary disease remains a challenge. Algorithms must be tailored to improve decision-making. We assessed suitable criteria from which an algorithm for selection for endoscopic retrograde cholangiopancreatography (ERCP) or magnetic resonance cholangiopancreatography could be developed. METHODS Data on clinical, ultrasound and liver function test findings and outcome were recorded for consecutive patients undergoing ERCP and patients were stratified into different indications and a therapeutic ratio (TR) obtained for each (TR = number of therapeutic ERCP/total number of ERCP). RESULTS One hundred and twenty ERCP were attempted with 112 cannulations (93.3%). Seventy-one therapeutic procedures were attempted with 64 (90.1%) successes. Forty-two (35%) investigations were normal. Seven (6%) patients suffered complications. Thirteen indications were used. The TR varied according to the indication. The TR for jaundice with biliary dilatation was 0.85. In contrast, asymptomatic patients with deranged liver function test and normal gall bladder on USS had a TR of 0.17. Gallstones with cholestatic liver function test yielded a TR of 0.54. A TR of 0.7 was considered an appropriate 'cut-off' for triage to ERCP or magnetic resonance cholangiopancreatography. An algorithm was generated based on these data. From this cohort, 50 (42%) patients would have been more appropriately investigated by magnetic resonance cholangiopancreatography, although 20 (40%) would have required therapy afterwards. CONCLUSIONS An algorithm that separates indications by TR (TR > 0.7) may provide a cost-efficient, patient-friendly pathway for investigation and improve the use of resources.
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Affiliation(s)
- John T Jenkins
- Department of Surgery, Royal Alexandra Hospital, Paisley, Scotland, UK
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Hiotis SP, Pachter HL. Liver and Biliary Tract. ACUTE CARE SURGERY 2007:479-496. [DOI: 10.1007/978-0-387-69012-4_31] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 01/03/2025]
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Siddiqui AA, Mitroo P, Kowalski T, Loren D. Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high-risk surgical patients: a decision analysis. Aliment Pharmacol Ther 2006; 24:1059-66. [PMID: 16984500 DOI: 10.1111/j.1365-2036.2006.03103.x] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 01/10/2023]
Abstract
BACKGROUND Laparoscopic cholecystectomy (LC) is recommended for patients with choledocholithiasis after ERCP with sphincterotomy (ES) and stone extraction. AIM We designed a decision model to address whether ES alone versus ES followed by LC (ES + LC) is the optimal treatment in high-risk patients with choledocholithiasis. METHODS Our cohort were patients with obstructive jaundice who have undergone an ES with biliary clearance. Recurrent biliary complications over a 2-year period stratified by gallbladder status (in/out) and age-stratified surgical complication rates were obtained from the literature. Failure of therapy was defined as either recurrent symptoms or death attributed to biliary complications. RESULTS For age 70-79 years, ES failed in 15% whereas ES + LC failed in 17% of cases. Mortality in the EC + LC group was 3.4 times that of the ES alone cohort. For age 80+ years, ES was dominant with an incremental success rate of 8%. Mortality in the ES + LC was 7.6 times that of ES. For age <70, ES + LC was the dominant strategy with an incremental success rate 5%. Sensitivity analysis in the groups confirmed our conclusions. CONCLUSIONS Management of choledocholithiasis by ES and stone clearance, but without cholecystectomy, should be considered for patients aged 70+. For low-risk patients, ES + LC should be performed to prevent recurrent biliary complications.
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Affiliation(s)
- A A Siddiqui
- Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA.
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Otsuki M, Hirota M, Arata S, Koizumi M, Kawa S, Kamisawa T, Takeda K, Mayumi T, Kitagawa M, Ito T, Inui K, Shimosegawa T, Tanaka S, Kataoka K, Saisho H, Okazaki K, Kuroda Y, Sawabu N, Takeyama Y. Consensus of primary care in acute pancreatitis in Japan. World J Gastroenterol 2006; 12:3314-23. [PMID: 16733846 PMCID: PMC4087886 DOI: 10.3748/wjg.v12.i21.3314] [Citation(s) in RCA: 37] [Impact Index Per Article: 1.9] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
The incidence of acute pancreatitis in Japan is increasing and ranges from 187 to 347 cases per million populations. Case fatality was 0.2% for mild to moderate, and 9.0% for severe acute pancreatitis in Japan in 2003. Experts in pancreatitis in Japan made this document focusing on the practical aspects in the early management of patients with acute pancreatitis. The correct diagnosis of acute pancreatitis and severity stratification should be made in all patients using the criteria for the diagnosis of acute pancreatitis and the multifactor scoring system proposed by the Research Committee of Intractable Diseases of the Pancreas as early as possible. All patients diagnosed with acute pancreatitis should be managed in the hospital. Monitoring of blood pressure, pulse and respiratory rate, body temperature, hourly urinary volume, and blood oxygen saturation level is essential in the management of such patients. Early vigorous intravenous hydration is of foremost importance to stabilize circulatory dynamics. Adequate pain relief with opiates is also important. In severe acute pancreatitis, prophylactic intravenous administration of antibiotics at an early stage is recommended. Administration of protease inhibitors should be initiated as soon as the diagnosis of acute pancreatitis is confirmed. A combination of enteral feeding with parenteral nutrition from early stage is recommended if there are no clear signs and symptoms of ileus and gastrointestinal bleeding. Patients with severe acute pancreatitis should be transferred to ICU as early as possible to perform special measures such as continuous regional arterial infusion of protease inhibitors and antibiotics, and continuous hemodiafiltration. The Japanese Government covers medical care expense for severe acute pancreatitis as one of the projects of Research on Measures for Intractable Diseases.
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Affiliation(s)
- Makoto Otsuki
- Department of Gastroenterology and Metabolism, University of Occupational and Environmental Health, Japan, School of Medicine, Kitakyushu, Japan.
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Abstract
Conditions that necessitate surgery frequently arise in patients with chronic liver disease and cirrhosis. Because cirrhosis has the ability to cause physiologic derangements in every organ system in the body, clinicians face significant challenges in preoperative preparation of the patient with cirrhosis in order to decrease postoperative morbidity and mortality. Emergent operations add an extra dimension of complexity to the clinical picture, due to limited preoperative time to prepare the patient with cirrhosis for surgery. In cases of severely decompensated cirrhosis, clinicians should have in their armamentarium possible alternatives to surgery that can be used to temporize the emergent nature of the disease and improve patient outcomes. The classification of cirrhotic liver disease by Child and Turcotte was initially utilized to predict mortality in patients undergoing surgically placed shunts for portal hypertensive bleeding. Subsequent studies have pointed to the fact that other general and thoracic surgery procedures can be assigned predicted mortality rates according to a similar classification scheme, the modified Child-Pugh score. Patients with cirrhosis facing surgery should undergo a careful history and physical examination and should be accurately placed into a designated Child-Pugh category. Because the modified Child-Pugh class is the most reliable determinant of postoperative morbidity and mortality, every attempt should be made to upgrade a patient's class in a favorable direction prior to surgery. Patients should be carefully evaluated for the presence of ascites and dietary alterations. In addition, medical management with diuretics should be employed to prevent postoperative ascites leak and possible infectious complications including bacterial peritonitis. Perhaps one of the most feared complications in the patient with cirrhosis facing surgery is hemorrhage. Because the liver is vital in maintenance of coagulation homeostasis, several pharmacologic adjuncts may be administered to correct any coagulopathy in the peri-operative period. Several diseases such as cholelithiasis and peptic ulcer disease are known to be more prevalent in the cirrhotic patient, and clinicians treating these diseases should have a thorough understanding of the pathophysiology of cirrhosis and portal hypertension. Patients with cirrhosis and portal hypertensive bleeding that are considered good surgical candidates (ie, Child-Pugh class A) may benefit from surgical portasystemic shunt in contrast to angiographically placed portacaval shunt (ie, transjugular intrahepatic portosystemic shunt ) due to the lack of durable patency and cost effectiveness in the latter. In patients with cirrhosis awaiting orthotopic liver transplantation, TIPS may be a lifesaving temporizing technique that is utilized as a bridge to transplantation.
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Affiliation(s)
- Christopher L Bell
- Department of Surgery, Methodist Hospital of Dallas, 221 West Colorado Blvd., Pavilion I, Suite 100, Dallas, TX 75208, USA
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