Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy

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.Keywords Acute biliary pancreatitis Á Cholecystectomy Á Endoscopic sphincterotomy Á ERCP Á Recurrent Acute biliary or gallstone pancreatitis (ABP) is an inflammatory condition of the pancreas induced by gallstones [1]. The initial treatment of ABP can be either conservative or interventional. The coexistence of cholangitis is an accepted indication for the performance of endoscopic retrograde cholangiopancreaticography (ERCP). However, whether this procedure is performed for patients with ABP depends on local expertise and guidelines, as is the decision to perform an endoscopic sphincterotomy (ES) [2][3][4][5].After patients have recovered from their first attack of ABP, most guidelines advocate a cholecystectomy to prevent a recurrent attack or other gallstone-related disorders such as symptomatic choledocholithiasis, cholecystitis, gallstone ileus, jaundice, and cholangitis [2][3][4][5]. ''Recurrent'' symptomatic choledocholithiasis after an initial attack of ABP may be preexisting common bile duct (CBD) stones not detected at the time of the primo episode or stones that migrated from the gallbladder into the CBD after initial stone clearance. Choledocholithiasis also may have developed newly within the bile duct after cholecystectomy.

Early cholecystectomy and ERCP are associated with reduced readmissions for acute biliary pancreatitis: a nationwide, population-based study

“…Intraoperative choledocholithiasis may be present in 13% to 24% of those undergoing cholecystectomy, and up to 3% to 6% of patients may be asymptomatic or have conditions not detectable by abdominal US or laboratory test parameters. 28 Additionally, gallstones may migrate from the gallbladder to the common bile duct in the interval between preoperative common bile duct stone clearance and surgery. The finding of higher readmission rates for ABP among those who underwent ERCP alone compared with those with combined intervention may be related to recurrence of choledocholithiasis in patients who retain their gallbladders, especially if they did not undergo endoscopic sphincterotomy.…”

Acute pancreatitis in pediatrics: a systematic review of the literature

“…Entretanto, a relação causal entre a presença do barro biliar e a ocorrência de PA não é completamente determinada, o que faz alguns autores não incluírem tal condição como etiologia de PA em crianças 10 . Além disso, exceto em casos de PA recorrente, não se indica de maneira rotineira a colecistectomia em pacientes com PA e barro biliar diagnosticado, ao contrário de pacientes com colelitíase e PA, cuja cirurgia deve ser realizada preferencialmente nas primeiras 2 semanas após a resolução do quadro agudo 11 .…”

Recurrent acute biliary pancreatitis: the protective role of cholecystectomy and endoscopic sphincterotomy

“…We read with great interest the article on recurrent acute biliary pancreatitis published in Surgical Endoscopy [1]. We appreciate the great efforts of the authors to gather all the published material regarding the subject.…”