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

Abstract

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

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

“…Fong et al 20 reported some reassuring data favoring EC performed during surgical necrosectomy in patients with necrotizing pancreatitis, showing no significant differences in postoperative mortality, overall morbidity, or bile duct injury compared with the control group. Similarly, Ackerman et al 45 compared 56 patients with moderately severe or severe ABP with 299 patients with mild ABP and showed that laparoscopic cholecystectomy could be performed safely, irrespective of severity. However, Nealon et al 26 assessed 78 patients with moderately severe or severe ABP who underwent EC and 109 patients who underwent DC, finding a complication rate after cholecystectomy of 44% in the former vs 5.5% in the latter.…”

Contemporary Surgical Management of Pancreatic Necrosis

“…In patients managed with operative transgastric necrosectomy, as described above, this is still a viable option. In patients managed with a step-up approach, there is a substantial risk of gallstone-related complications in the delay before cholecystectomy if it is deferred until resolution of necrosis, as high as 20% in recent studies . However, there is no evidence-based consensus on the optimal timing of cholecystectomy in step-up patients, and better evidence-based patient benchmarks are needed to determine this.…”

“…We tend to proceed when the acute phase of inflammation and necessary debridement have been performed, the patient is nutritionally replete, and the period of critical illness has passed. Multiple series have now shown a laparoscopic approach to be feasible and safe in the vast majority of these patients . While often performed at tertiary care centers where these patients receive their NP care, there is no evidence that this is necessary.…”

Early Surgical Treatment of Severe Acute Pancreatitis of Biliary Etiology

“…Показания к применению инвазивных пособий установлены в 10 (21,7%) случаях (лапароскопическая санация и дренирование сальниковой сумки и брюшной полости -4, холецистостомия -6). Средний койко-день в ОАР составил 3,0 (2,0-5,0) суток, средний общий (с учетом повторной госпитализации для удаления дренажа) койкодень -14,5 (11,(0)(1)(2)(3)(4)(5)(6)(7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17)(18)(19)9) суток (среди выписанных пациентов -14,0 (11,0-19,0) суток). Умерло 2 (4,3%) человека, рецидив ОПБЭ развился у 1 (55%).…”

“…Однако проблеме раннего оперативного лечения тяжелого ОПБЭ посвящены лишь единичные работы, что определяет ее актуальность [10][11][12][13][14][15][16]. В настоящее время диагностика и лечение ОП регламентированы клиническим протоколом «Диагностика и лечение пациентов (взрослое население) с острым панкреатитом при оказании медицинской помощи в стационарных условиях» [17] и рядом клинических руководств и международных доказательных практических рекомендаций [1-3, 18, 19].…”