The Timing of Biliary Surgery in Acute Pancreatitis

Abstract

The timing of biliary surgery remains controversial in patients with acute pancreatitis associated with cholelithiasis. Eighty hospital admissions for acute pancreatitis, occurring in 74 patients with cholelithiasis, have therefore been reviewed. Among 22 patients who underwent abdominal surgery during the first week of treatment, there were five deaths (23%) and four patients (18%) who required more than seven days of intensive care. Fifty-eight episodes of pancreatitis were managed nonoperatively during the first week of treatment, with no deaths, although six (10%) required more than seven days of intensive care. Biliary surgery was undertaken later during the same admission in 37 patients, with no deaths. Twenty-one patients were discharged without biliary operation, but seven (33%) developed further pancreatitis. Previously reported prognostic signs were used to divide pancreatitis into 57 "mild" episodes (1.8% mortality) and 23 "severe" episodes (17% mortality). Early (day 0-7) definitive biliary surgery was undertaken in 11 patients with "mild" pancreatitis, with one death (9%), and in six patients with "severe" pancreatitis, with four deaths (67%). In three recent patients with "severe" pancreatitis, early biliary surgery was limited to cholecystostomy, with no deaths. These findings suggest that although early correction of associated biliary disease may be undertaken safely in many patients with "mild" acute pancreatitis, early definitive surgery is hazardous in "severe" pancreatitis and should, if possible, be deferred until pancreatitis has subsided. In most patients biliary surgery should precede hospital discharge.

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

“…The evidence that does exist originates mainly from older retrospective studies that observed no recurrent ABP after a cholecystectomy compared with a 25% to 61% rate of ABP recurrence with conservative management [11][12][13][14][15][16][17]. From a retrospective population-based cohort study, it was concluded that a cholecystectomy reduces the risk of a recurrent or de novo ABP almost to the same level as found in the general population [18].…”

The efficacy of magnetic resonance cholangiopancreatography in assessing the etiology of acute idiopathic pancreatitis

“…Mohan et al while evaluating the relative roles of MRCP and EUS in investigating CBD calculi "evidence based practice" methods concluded MRCP should be the first line of investigation of CBD calculi [19]. The frequency and morbidity of recurrent pancreatitis are great, as undiagnosed biliary disease carries a recurrence rate of 20-50%, whereas the risk of recurrent pancreatitis associated with biliary stones decreases to less than 5% after corrective surgery [20,21].…”

Acute Biliary Pancreatitis

“…Studies done to date have demonstrated a risk of recurrent biliary pancreatitis from 25 to 63% when cholecystectomy was delayed until after discharge from the index hospitalization. 30,31,32 In a retrospective observational study of 281 patients with ABP, Ito et al demonstrated gallstone-related complications in 33% of patients who did not have index cholecystectomy, with recurrent ABP found in 13.4% of patients (versus no recurrences in the index cholecystectomy group). Of note, almost one third of recurrences occurred within 2 weeks after discharge, and half of recurrences occurred within 4 weeks.33 They also looked at ERCP with ES as definitive treatment in 42 out of the 119 patients who did not have index cholecystectomy.…”