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Portincasa P, Di Ciaula A, Bonfrate L, Stella A, Garruti G, Lamont JT. Metabolic dysfunction-associated gallstone disease: expecting more from critical care manifestations. Intern Emerg Med 2023; 18:1897-1918. [PMID: 37455265 PMCID: PMC10543156 DOI: 10.1007/s11739-023-03355-z] [Citation(s) in RCA: 6] [Impact Index Per Article: 6.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/19/2023] [Accepted: 06/22/2023] [Indexed: 07/18/2023]
Abstract
About 20% of adults worldwide have gallstones which are solid conglomerates in the biliary tree made of cholesterol monohydrate crystals, mucin, calcium bilirubinate, and protein aggregates. About 20% of gallstone patients will definitively develop gallstone disease, a condition which consists of gallstone-related symptoms and/or complications requiring medical therapy, endoscopic procedures, and/or cholecystectomy. Gallstones represent one of the most prevalent digestive disorders in Western countries and patients with gallstone disease are one of the largest categories admitted to European hospitals. About 80% of gallstones in Western countries are made of cholesterol due to disturbed cholesterol homeostasis which involves the liver, the gallbladder and the intestine on a genetic background. The incidence of cholesterol gallstones is dramatically increasing in parallel with the global epidemic of insulin resistance, type 2 diabetes, expansion of visceral adiposity, obesity, and metabolic syndrome. In this context, gallstones can be largely considered a metabolic dysfunction-associated gallstone disease, a condition prone to specific and systemic preventive measures. In this review we discuss the key pathogenic and clinical aspects of gallstones, as the main clinical consequences of metabolic dysfunction-associated disease.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy.
| | - Agostino Di Ciaula
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy
| | - Leonilde Bonfrate
- Clinica Medica "A. Murri", Division of Internal Medicine, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, p.zza Giulio Cesare 11, 70124, Bari, Italy
| | - Alessandro Stella
- Laboratory of Medical Genetics, Department of Precision and Regenerative Medicine and Ionian Area (DIMEPRE-J), University of Bari Aldo Moro, Bari, Italy
| | - Gabriella Garruti
- Section of Endocrinology, Department of Preventive and Regenerative Medicine and Ionian Area (DiMePrev-J), University of Bari Aldo Moro, Bari, Italy
| | - John Thomas Lamont
- Division of Gastroenterology, Department of Medicine, Beth Israel Deaconess Medical Center and Harvard Medical School, Boston, MA, 02215, USA
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Hajibandeh S, Jurdon R, Heaton E, Hajibandeh S, O'Reilly D. The risk of recurrent pancreatitis after first episode of acute pancreatitis in relation to etiology and severity of disease: A systematic review, meta-analysis and meta-regression analysis. J Gastroenterol Hepatol 2023; 38:1718-1733. [PMID: 37366550 DOI: 10.1111/jgh.16264] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 04/08/2023] [Accepted: 06/05/2023] [Indexed: 06/28/2023]
Abstract
BACKGROUND AND AIM The study aims to determine and quantify the stratified risk of recurrent pancreatitis (RP) after the first episode of acute pancreatitis in relation to etiology and severity of disease. METHODS A systematic review and meta-analysis in compliance with PRISMA statement standards was conducted. A search of electronic information sources was conducted to identify all studies investigating the risk of RP after the first episode of acute pancreatitis. Proportion meta-analysis models using random effects were constructed to calculate the weighted summary risks of RP. Meta-regression was performed to evaluate the effect of different variables on the pooled outcomes. RESULTS Analysis of 57,815 patients from 42 studies showed that the risk of RP after first episode was 19.8% (95% confidence interval [CI] 17.5-22.1%). The risk of RP was 11.9% (10.2-13.5%) after gallstone pancreatitis, 28.7% (23.5-33.9%) after alcohol-induced pancreatitis, 30.3% (15.5-45.0%) after hyperlipidemia-induced pancreatitis, 38.1% (28.9-47.3%) after autoimmune pancreatitis, 15.1% (11.6-18.6%) after idiopathic pancreatitis, 22.0% (16.9-27.1%) after mild pancreatitis, 23.9% (12.9-34.8%) after moderate pancreatitis, 21.6% (14.6-28.7%) after severe pancreatitis, and 6.6% (4.1-9.2%) after cholecystectomy following gallstone pancreatitis. Meta-regression confirmed that the results were not affected by the year of study (P = 0.541), sample size (P = 0.064), length of follow-up (P = 0.348), and age of patients (P = 0.138) in the included studies. CONCLUSIONS The risk of RP after the first episode of acute pancreatitis seems to be affected by the etiology of pancreatitis but not the severity of disease. The risks seem to be higher in patients with autoimmune pancreatitis, hyperlipidemia-induced pancreatitis, and alcohol-induced pancreatitis and lower in patients with gallstone pancreatitis and idiopathic pancreatitis.
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Affiliation(s)
- Shahab Hajibandeh
- Department of General Surgery, University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff, UK
| | | | - Emily Heaton
- James Cook University Hospital, Middlesbrough, UK
| | - Shahin Hajibandeh
- Department of General Surgery, Royal Stoke University Hospital, Stoke-on-Trent, UK
| | - David O'Reilly
- Department of General Surgery, University Hospital of Wales, Cardiff and Vale NHS Trust, Cardiff, UK
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Bruno MJ. Endoscopy in Gallstone Pancreatitis. Gastrointest Endosc Clin N Am 2023; 33:701-707. [PMID: 37709405 DOI: 10.1016/j.giec.2023.04.003] [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: 09/16/2023]
Abstract
The root cause for biliary pancreatitis is a transient impediment of the outflow of secretion from the pancreatic duct due to gallstones and sludge obstructing the ampulla of Vater. Based on meta-analyses and recent studies, clear recommendations can be formulated when and when not to perform an ERC in patients with biliary pancreatitis. ERC is indicated urgently in patients with biliary pancreatitis and concomitant cholangitis. Urgent ERC is not indicated in patients with predicted mild or severe biliary pancreatitis without cholangitis, even when stones or sludge are proven on EUS imaging.
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Affiliation(s)
- Marco J Bruno
- Department of Gastroenterology & Hepatology, Erasmus University Medical Center, Doctor Molewaterplein 40, Rotterdam 3015 GD, the Netherlands.
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4
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Tozlu M, Karaca B, Acar S, Toka B, Karacaer C, Eminler AT, Köksal AS. Higher Complications During the Waiting Period for Interval Cholecystectomy in Patients With Mild Biliary Pancreatitis. Surg Laparosc Endosc Percutan Tech 2022; 32:655-660. [PMID: 36468890 DOI: 10.1097/sle.0000000000001094] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 04/18/2022] [Accepted: 07/06/2022] [Indexed: 06/17/2023]
Abstract
BACKGROUND Although current guidelines recommend cholecystectomy during the same admission in patients with mild acute biliary pancreatitis (ABP), it involves a waiting list most of the time. We aimed to assess the risk of complications and determine predictors during the waiting period for cholecystectomy after the first episode of ABP. METHODS A prospective observational study was conducted in patients with mild ABP. Follow-ups were done by phone calls or using electronic health records for a maximum of 6 months after discharge or until cholecystectomy. RESULTS A total of 194 patients were included in the study. Although all patients were referred to surgeons, only 81 (41.8%) underwent cholecystectomy within 6 months after discharge. During the observation period, gallstone-related biliary events (GRBEs) developed in 68 (35.1%) patients, which included biliary colic, recurrent ABP, acute cholecystitis, choledocholithiasis, gallbladder perforation, cholangitis, and liver abscess. The overall readmission rate was 25.2%, with 44.8% occurred within 4 weeks after discharge. The odds ratio of any complication was 1.58 (95% CI, 1.42 to 1.76, P =0.028) and 1.59 (95% CI, 1.42 to 1.78, P =0.009) in the patients who did not have surgery within 2 to 7 days and 8 to 15 days, respectively. A 4-fold increased risk of readmission was detected (95% CI, 1.16 to 13.70, P =0.019) if cholecystectomy was not performed within 31 to 90 days. The patients who developed complications had significantly higher C-reactive protein at admission, longer waiting time, and had 3 or more gallstones on imaging. CONCLUSIONS Interval cholecystectomy was associated with a high risk of complications during the waiting period in patients with mild ABP.
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Affiliation(s)
| | - Busra Karaca
- Internal Medicine, Sakarya University Faculty of Medicine, Sakarya
| | | | - Bilal Toka
- Department of Gastroenterology, Silivri Anadolu Hospital, Istanbul, Turkey
| | - Cengiz Karacaer
- Internal Medicine, Sakarya University Faculty of Medicine, Sakarya
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Podda M, Pacella D, Pellino G, Coccolini F, Giordano A, Di Saverio S, Pata F, Ielpo B, Virdis F, Damaskos D, De Simone B, Agresta F, Sartelli M, Leppaniemi A, Riboni C, Agnoletti V, Mole D, Kluger Y, Catena F, Pisanu A. coMpliAnce with evideNce-based cliniCal guidelines in the managemenT of acute biliaRy pancreAtitis): The MANCTRA-1 international audit. Pancreatology 2022; 22:902-916. [PMID: 35963665 DOI: 10.1016/j.pan.2022.07.007] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/17/2022] [Revised: 06/24/2022] [Accepted: 07/12/2022] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Reports about the implementation of recommendations from acute pancreatitis guidelines are scant. This study aimed to evaluate, on a patient-data basis, the contemporary practice patterns of management of biliary acute pancreatitis and to compare these practices with the recommendations by the most updated guidelines. METHODS All consecutive patients admitted to any of the 150 participating general surgery (GS), hepatopancreatobiliary surgery (HPB), internal medicine (IM) and gastroenterology (GA) departments with a diagnosis of biliary acute pancreatitis between 01/01/2019 and 31/12/2020 were included in the study. Categorical data were reported as percentages representing the proportion of all study patients or different and well-defined cohorts for each variable. Continuous data were expressed as mean and standard deviation. Differences between the compliance obtained in the four different subgroups were compared using the Mann-Whitney U, Student's t, ANOVA or Kruskal-Wallis tests for continuous data, and the Chi-square test or the Fisher's exact test for categorical data. RESULTS Complete data were available for 5275 patients. The most commonly discordant gaps between daily clinical practice and recommendations included the optimal timing for the index CT scan (6.1%, χ2 6.71, P = 0.081), use of prophylactic antibiotics (44.2%, χ2 221.05, P < 0.00001), early enteral feeding (33.2%, χ2 11.51, P = 0.009), and the implementation of early cholecystectomy strategies (29%, χ2 354.64, P < 0.00001), with wide variability based on the admitting speciality. CONCLUSIONS The results of this study showed an overall poor compliance with evidence-based guidelines in the management of ABP, with wide variability based on the admitting speciality. Study protocol registered in ClinicalTrials.Gov (ID Number NCT04747990).
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Affiliation(s)
- Mauro Podda
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy.
| | - Daniela Pacella
- University of Naples Federico II, Department of Public Health, Naples, Italy
| | - Gianluca Pellino
- 'Luigi Vanvitelli' University of Campania, Naples, Italy; Colorectal Surgery, Vall d'Hebron University Hospital, Barcelona, Spain
| | - Federico Coccolini
- General, Emergency and Trauma Surgery Unit, Pisa University Hospital, Pisa, Italy
| | - Alessio Giordano
- Department of General Surgery, Santo Stefano Hospital, Prato, Italy
| | - Salomone Di Saverio
- Department of Surgery, Madonna del Soccorso Hospital, San Benedetto del Tronto, Italy
| | - Francesco Pata
- General Surgery Unit, Nicola Giannettasio Hospital, Corigliano-Rossano, Italy
| | | | - Francesco Virdis
- Trauma and Acute Care Surgery Unit, Niguarda Ca Granda Hospital, Milan, Italy
| | - Dimitrios Damaskos
- Department of Upper GI Surgery, Royal Infirmary of Edinburgh, Edinburgh, Scotland, UK
| | - Belinda De Simone
- Department of Emergency and Metabolic Minimally Invasive Surgery, Centre Hospitalier Intercommunal de Poissy/Saint Germain en Laye, Poissy Cedex, France
| | - Ferdinando Agresta
- Department of Surgery, Vittorio Veneto Civil Hospital, Vittorio Veneto, Italy
| | | | - Ari Leppaniemi
- Department of Abdominal Surgery, Abdominal Center, University of Helsinki and Helsinki University Central Hospital, Helsinki, Finland
| | - Cristiana Riboni
- Department of Surgery, EOC Regional Hospital, Lugano, Switzerland
| | | | - Damian Mole
- Centre for Inflammation Research, Clinical Surgery, University of Edinburgh, Edinburgh, Scotland, UK
| | - Yoram Kluger
- Division of General Surgery, Rambam Health Care Campus, Haifa, Israel
| | - Fausto Catena
- Department of Emergency and Trauma Surgery, Bufalini Hospital, Cesena, Italy
| | - Adolfo Pisanu
- Department of Surgical Science, Emergency Surgery Unit, University of Cagliari, Cagliari, Italy
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Blundell JD, Gandy RC, Close J, Harvey L. Cholecystectomy for people aged 50 years or more with mild gallstone pancreatitis: predictors and outcomes of index and interval procedures. Med J Aust 2022; 217:246-252. [PMID: 35452133 PMCID: PMC9545298 DOI: 10.5694/mja2.51492] [Citation(s) in RCA: 5] [Impact Index Per Article: 2.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/29/2021] [Accepted: 01/25/2022] [Indexed: 12/13/2022]
Abstract
Objectives To estimate the proportions of people aged 50 years or more with mild gallstone pancreatitis who undergo index cholecystectomy (during their initial hospital admission) or interval cholecystectomy (during a subsequent admission); to compare outcomes following index and interval cholecystectomy; and to identify factors associated with undergoing interval cholecystectomy. Design, setting, participants Analysis of linked hospitalisation and deaths data for all people aged 50 years or more with mild gallstone pancreatitis who underwent cholecystectomy in New South Wales within twelve months of their index admission, 1 July 2008 ‒ 30 June 2018. Main outcome measures Cholecystectomy classification (index or interval). Secondary outcomes: all‐cause mortality (30‒365 days), emergency re‐admissions with gallstone‐related disease (within 28 or 180 days of discharge); hospital lengths of stay (index admission, and all admissions with gallstone‐related disease over six months). Results A total of 1836 patients underwent index cholecystectomy (37.9%) and 3003 interval cholecystectomy (62.1%). Mortality to twelve months was similar in the two groups. Larger proportions of people who underwent interval cholecystectomy were re‐admitted within 28 days (246, 8.2% v 23, 1.3%) or 180 days (527, 17.6% v 59, 3.2%), or required open cholecystectomy (238, 7.9% v 69, 3.8%). Mean index admission length of stay was longer for index than interval cholecystectomy (7.7 [SD, 4.7] days v 5.3 [SD, 3.9] days), but six‐month total length of stay was similar (8.2 [SD, 5.6] days v 7.9 [SD, 5.8] days). Interval cholecystectomy was more likely for patients with three or more comorbid conditions (adjusted odds ratio [aOR], 1.29; 95% CI, 1.08‒1.55) or private health insurance (aOR, 1.31; 95% CI, 1.13‒1.51), and for those admitted to low surgical volume hospitals (aOR, 1.84; 95% CI, 1.03‒3.31). Conclusions Most NSW people over 50 with mild gallstone pancreatitis did not undergo index cholecystectomy, despite recommendations in international guidelines. Delayed cholecystectomy was associated with more frequent open cholecystectomy procedures and gallstone disease‐related emergency re‐admissions, as well as with low or medium hospital surgical volume, comorbidity, and having private insurance.
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Affiliation(s)
- Jian D Blundell
- Prince of Wales Hospital and Community Health Services Sydney NSW
- Falls, Balance and Injury Research Centre Neuroscience Research Australia Sydney NSW
| | - Robert C Gandy
- Prince of Wales Hospital and Community Health Services Sydney NSW
- Prince of Wales Clinical School University of New South Wales Sydney NSW
| | - Jacqueline Close
- Falls, Balance and Injury Research Centre Neuroscience Research Australia Sydney NSW
- Prince of Wales Clinical School University of New South Wales Sydney NSW
| | - Lara Harvey
- Falls, Balance and Injury Research Centre Neuroscience Research Australia Sydney NSW
- University of New South Wales Sydney NSW
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7
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Rios-Diaz AJ, Lamm R, Metcalfe D, Devin CL, Pucci MJ, Palazzo F. National recurrence of pancreatitis and readmissions after biliary pancreatitis. Surg Endosc 2022; 36:7399-7408. [PMID: 35233658 DOI: 10.1007/s00464-022-09153-6] [Citation(s) in RCA: 2] [Impact Index Per Article: 1.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 10/24/2021] [Accepted: 02/17/2022] [Indexed: 10/19/2022]
Abstract
BACKGROUND National and international guidelines support early cholecystectomy after mild gallstone pancreatitis but a recent nationwide study suggested these recommendations are not universally followed. Our study sought to quantify the national utilization of same hospitalization cholecystectomy versus non-operative management (NOM) and its association with pancreatitis recurrence, readmissions, and costs after mild gallstone pancreatitis (GP). METHODS Adult patients admitted with mild GP were identified from the Nationwide Readmission Database 2010-2015. Primary outcomes included the rate of cholecystectomy during the index admission as well as pancreatitis recurrence and readmission at 30 and 180 days (30d, 180d) comparing NOM to same hospitalization cholecystectomy. Mortality upon readmission, total length of stay (LOS), and total costs (combined index-readmission hospital costs) were also explored. Cox proportional hazards regression and generalized linear models controlled for patient/hospital confounders. RESULTS Among the 65,067 patients identified, 30% underwent cholecystectomy. The NOM cohort was older (58 vs. 50 years), had more comorbidities (Charlson index > 2, 23.5% vs. 11.5%), fewer female patients (56.7% vs. 67%) and less discharge-to-home (84.9% vs. 94.4%) (all p < 0.001). NOM was associated with increase in recurrence and unplanned readmissions at 30d [Hazard Ratio 3.53 (95% CI 2.92-4.27), 2.41 (2.11-2.74), respectively], and 180d [4.27 (3.65-4.98), 2.78 (2.54-3.04), respectively], as well as increased mortality during 180d readmission 1.88 (1.06-3.35). This approach was also associated with significant increase in LOS [predicted mean difference 2.79 days (95% CI 2.46-3.12)] and total costs [$2507.89 ($1714.4-$3301.4)]. CONCLUSIONS In the USA, most patients presenting with mild GP do not undergo same hospitalization cholecystectomy. This strategy results in higher recurrent pancreatitis, mortality during readmission, and an additional $4.85 M/year in hospital costs nationwide. These data support same hospitalization cholecystectomy as the gold standard for mild GP.
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Affiliation(s)
- Arturo J Rios-Diaz
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA.
| | - Ryan Lamm
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - David Metcalfe
- Rheumatology and Musculoskeletal Sciences (NDORMS), Nuffield Department of Orthopedics, John Radcliffe Hospital, University of Oxford, Oxford, UK
| | - Courtney L Devin
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - Michael J Pucci
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
| | - Francesco Palazzo
- Department of Surgery, Thomas Jefferson University Hospital, 1015 Walnut Street, Philadelphia, PA, 19107, USA
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Walayat S, Baig M, Puli SR. Early vs late cholecystectomy in mild gall stone pancreatitis: An updated meta-analysis and review of literature. World J Clin Cases 2021; 9:3038-3047. [PMID: 33969089 PMCID: PMC8080749 DOI: 10.12998/wjcc.v9.i13.3038] [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: 12/17/2020] [Revised: 02/07/2021] [Accepted: 03/11/2021] [Indexed: 02/06/2023] Open
Abstract
BACKGROUND Gallstone pancreatitis is one of the most common causes of acute pancreatitis. Cholecystectomy remains the definitive treatment of choice to prevent recurrence. The rate of early cholecystectomies during index admission remains low due to perceived increased risk of complications.
AIM To compare outcomes including length of stay, duration of surgery, biliary complications, conversion to open cholecystectomy, intra-operative, and post-operative complications between patients who undergo cholecystectomy during index admission as compared to those who undergo cholecystectomy thereafter.
METHODS Statistical Method: Pooled proportions were calculated using both Mantel-Haenszel method (fixed effects model) and DerSimonian Laird method (random effects model).
RESULTS Initial search identified 163 reference articles, of which 45 were selected and reviewed. Eighteen studies (n = 2651) that met the inclusion criteria were included in this analysis. Median age of patients in the late group was 43.8 years while that in the early group was 43.6. Pooled analysis showed late laparoscopic cholecystectomy group was associated with an increased length of stay by 88.96 h (95%CI: 86.31 to 91.62) as compared to early cholecystectomy group. Pooled risk difference for biliary complications was higher by 10.76% (95%CI: 8.51 to 13.01) in the late cholecystectomy group as compared to the early cholecystectomy group. Pooled analysis showed no risk difference in intraoperative complications [risk difference: 0.41%, (95%CI: -1.58 to 0.75)], postoperative complications [risk difference: 0.60%, (95%CI: -2.21 to 1.00)], or conversion to open cholecystectomy [risk difference: 1.42%, (95%CI: -0.35 to 3.21)] between early and late cholecystectomy groups. Pooled analysis showed the duration of surgery to be prolonged by 39.11 min (95%CI: 37.44 to 40.77) in the late cholecystectomy group as compared to the early group.
CONCLUSION In patients with mild gallstone pancreatitis early cholecystectomy leads to shorter hospital stay, shorter duration of surgery, while decreasing the risk of biliary complications. Rate of intraoperative, post-operative complications and chances of conversion to open cholecystectomy do not significantly differ whether cholecystectomy was performed early or late.
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Affiliation(s)
- Saqib Walayat
- Department of Internal Medicine, OSF Saint Francis Medical Center, University of Illinois Peoria Campus, Peoria, IL 61637, United States
| | - Muhammad Baig
- Department of Gastroenterology, University of Illinois, Peoria, IL 61637, United States
| | - Srinivas R Puli
- Department of Medicine, University of Illinois-Peoria, Peoria, IL 61604, United States
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9
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Hegab YH, Hassan AO, Metwalli AEM, Awad JR, Orban YA. Adherence to the evidence-based guidelines in the management of acute biliary pancreatitis: A case series. Int J Surg Case Rep 2020; 77:906-914. [PMID: 33395922 PMCID: PMC7749290 DOI: 10.1016/j.ijscr.2020.11.135] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/11/2020] [Revised: 11/27/2020] [Accepted: 11/29/2020] [Indexed: 01/03/2023] Open
Abstract
BACKGROUND Acute pancreatitis (AP) is considered one of the most common gastrointestinal disorders; the annual worldwide incidence for AP is 4.9-73.4 cases / 100,000 people and the total mortality rate is 4-8%, increasing to 33% in patients with infected necrosis. This study aims to assess the outcome of providing standardized evidence-based care to patients with acute biliary pancreatitis. METHODS Thirty patients diagnosed with acute biliary pancreatitis, were enrolled in this study and managed according to the Japanese guidelines, 2015 with a complementary scope on other recent guidelines. RESULTS Out of 30 patients in the study, 60% were females. Twenty-five cases were presented in the early phase of the disease while the rest presented in the late phase. Gallstones were the commonest cause (80%). The complications encountered were a systemic complication in one case, organ failure in three cases, and the local complications in the form of fluid collections in (43.3%) of cases.Out of 30 patients, 6 patients had an intervention. The main approach was minimally invasive techniques (4 cases), Open approach was performed in 2 cases. The total mortality rate was 10%. Most mild cases were discharged within one week from admission. Cases readmitted with recurrent attacks of acute pancreatitis were 3 cases, one male and 2 females. CONCLUSION By applying guidelines in the management of acute biliary pancreatitis, we can reduce disease-related morbidity and mortality. Besides, we can reduce the costs of medical services with the proper investment of healthcare resources.
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Affiliation(s)
| | - Ahmed Osama Hassan
- Department of Pediatric Surgery, Faculty of Medicine, Zagazig University, Egypt.
| | | | - Joseph Ri Awad
- Department of Surgery, Faculty of Medicine, Zagazig University, Egypt.
| | - Yasser A Orban
- Department of Surgery, Faculty of Medicine, Zagazig University, Egypt.
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10
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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: 7] [Impact Index Per Article: 1.4] [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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11
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Wang Y, Liu Z, Chen S, Ye X, Xie W, Hu C, Iezzi T, Jackson T. Identifying At-Risk Subgroups for Acute Postsurgical Pain: A Classification Tree Analysis. PAIN MEDICINE 2019; 19:2283-2295. [PMID: 29370426 DOI: 10.1093/pm/pnx339] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.4] [Reference Citation Analysis] [Abstract] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 02/02/2023]
Abstract
Objective Acute postsurgical pain is common and has potentially negative long-term consequences for patients. In this study, we evaluated effects of presurgery sociodemographics, pain experiences, psychological influences, and surgery-related variables on acute postsurgical pain using logistic regression vs classification tree analysis (CTA). Design The study design was prospective. Setting This study was carried out at Chongqing No. 9 hospital, Chongqing, China. Subjects Patients (175 women, 84 men) completed a self-report battery 24 hours before surgery (T1) and pain intensity ratings 48-72 hours after surgery (T2). Results An initial logistic regression analysis identified pain self-efficacy as the only presurgery predictor of postoperative pain intensity. Subsequently, a classification tree analysis (CTA) indicated that lower vs higher acute postoperative pain intensity levels were predicted not only by pain self-efficacy but also by its interaction with disease onset, pain catastrophizing, and body mass index. CTA results were replicated within a revised logistic regression model. Conclusions Together, these findings underscored the potential utility of CTA as a means of identifying patient subgroups with higher and lower risk for severe acute postoperative pain based on interacting characteristics.
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Affiliation(s)
- Yang Wang
- Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Zejun Liu
- Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Shuanghong Chen
- Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Xiaoxuan Ye
- Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China
| | - Wenyi Xie
- Beibei Chinese Medicine Hospital, Chongqing, China
| | - Chunrong Hu
- Department of Rheumatology and Immunology, Chongqing Number 9 Hospital, Chongqing, China
| | - Tony Iezzi
- Department of Psychology, London Health Sciences Centre, London, Canada
| | - Todd Jackson
- Key Laboratory of Cognition and Personality, Southwest University, Chongqing, China.,Department of Psychology, University of Macau, Macau, China
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12
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Moody N, Adiamah A, Yanni F, Gomez D. Meta-analysis of randomized clinical trials of early versus delayed cholecystectomy for mild gallstone pancreatitis. Br J Surg 2019; 106:1442-1451. [PMID: 31268184 DOI: 10.1002/bjs.11221] [Citation(s) in RCA: 29] [Impact Index Per Article: 5.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/30/2018] [Revised: 03/14/2019] [Accepted: 04/03/2019] [Indexed: 12/20/2022]
Abstract
BACKGROUND Gallstones account for 30-50 per cent of all presentations of acute pancreatitis. While the management of acute pancreatitis is usually supportive, definitive treatment of gallstone pancreatitis is cholecystectomy. Guidelines from the British Society of Gastroenterology suggest definitive treatment on index admission or within 2 weeks of discharge, whereas joint recommendations from the International Association of Pancreatology and the American Pancreatic Association recommend definitive treatment on index admission. Evidence suggests that uptake of these guidelines is low. METHODS Embase, MEDLINE and Cochrane databases were searched for RCTs investigating early versus delayed cholecystectomy in patients with a confirmed diagnosis of mild gallstone pancreatitis. The pooled synthesis was undertaken using a random-effects meta-analysis of the primary outcome of recurrent biliary complications causing hospital readmission. Secondary outcomes included intraoperative and postoperative complications, and total length of hospital stay (LOS). All analyses were performed using RevMan5 software. RESULTS Five RCTs were identified, which included 629 patients (318 in the early cholecystectomy (EC) group and 311 in the delayed cholecystectomy (DC) group). Recurrent biliary events that required readmission were reduced in patients undergoing EC compared with the number in patients having DC (odds ratio (OR) 0·17, 95 per cent c.i. 0·09 to 0·33). There was no difference in the rate of intraoperative (OR 0·58, 0·17 to 1·92) or postoperative (OR 0·78, 0·38 to 1·62) complications. CONCLUSION EC following mild gallstone pancreatitis does not increase the risk of intraoperative or postoperative complications, but reduces the readmission rate for recurrent biliary complications.
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Affiliation(s)
- N Moody
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - A Adiamah
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - F Yanni
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
| | - D Gomez
- Department of Hepatobiliary and Pancreatic Surgery, Nottingham Digestive Diseases Centre and National Institute for Health Research (NIHR) Nottingham Biomedical Research Centre, Nottingham University Hospitals NHS Trust, Queen's Medical Centre, Nottingham, UK
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13
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Bilal M, Kline KT, Trieu JA, Saraireh H, Desai M, Parupudi S, Abougergi MS. Trends in same-admission cholecystectomy and endoscopic retrograde cholangiopancreatography for acute gallstone pancreatitis: A nationwide analysis across a decade. Pancreatology 2019; 19:524-530. [PMID: 31036491 DOI: 10.1016/j.pan.2019.04.008] [Citation(s) in RCA: 20] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 01/28/2019] [Revised: 04/05/2019] [Accepted: 04/18/2019] [Indexed: 12/11/2022]
Abstract
BACKGROUND/OBJECTIVES Gallstones are the leading cause of acute pancreatitis in developed countries. National and international guidelines recommend that a cholecystectomy should be performed during the index hospitalization for acute gallstone pancreatitis. We aimed to delineate the national trends for same-admission cholecystectomy and ERCP for acute gallstone pancreatitis over the last ten years. METHODS We used the 2004, 2009 and 2014 National Inpatient Sample database including patients with a principal diagnosis of acute pancreatitis and a secondary diagnosis of choledocholithiasis or cholelithiasis. Exclusion criteria were age <18 years and elective admission. Primary outcome was the trend in incidence rate of same admission cholecystectomy from 2004 to 2014. The secondary outcomes were: 10-year trend in 1) Incidence of gallstone pancreatitis, 2) proportion of gallstone pancreatitis compared to all other etiologies of acute pancreatitis, 3) incidence rate of same-admission ERCP, 4) length of hospital stay, and 5) total hospitalization costs and charges. RESULTS The proportion of admissions during which a same-admission cholecystectomy was performed decreased from 48.7% in 2004 to 46.9% in 2009 to 45% in 2014 (trend p < 0.01). During the same time interval, the percentage of admissions during which an ERCP was performed decreased from 25.1% to 18.7% (Trend p < 0.01). CONCLUSIONS Adherence to the guidelines for same-admission cholecystectomy for patients admitted with acute gallstone pancreatitis have been declining over the past decade. On the other hand, decline in rate of ERCP in patients with acute gallstone pancreatitis and no signs of cholangitis demonstrates adherence to guidelines in this regard.
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Affiliation(s)
- Mohammad Bilal
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, USA.
| | - Kevin T Kline
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Judy A Trieu
- Department of Internal Medicine, The University of Texas Medical Branch, Galveston, TX, USA
| | - Hamzeh Saraireh
- Division of Gastroenterology & Hepatology, Virginia Commonwealth University, Richmond, VA, USA
| | - Madhav Desai
- University of Kansas Medical Center, Kansas City, KS, USA
| | - Sreeram Parupudi
- Division of Gastroenterology & Hepatology, The University of Texas Medical Branch, Galveston, TX, USA
| | - Marwan S Abougergi
- Catalyst Medical Consulting, Simpsonville, SC, USA; University of South Carolina School of Medicine, Columbia, SC, USA
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14
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Portincasa P, Molina-Molina E, Garruti G, Wang DQH. Critical Care Aspects of Gallstone Disease. J Crit Care Med (Targu Mures) 2019; 5:6-18. [PMID: 30766918 PMCID: PMC6369569 DOI: 10.2478/jccm-2019-0003] [Citation(s) in RCA: 14] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Grants] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 12/05/2018] [Accepted: 01/08/2019] [Indexed: 12/15/2022] Open
Abstract
Approximately twenty per cent of adults have gallstones making it one of the most prevalent gastrointestinal diseases in Western countries. About twenty per cent of gallstone patients requires medical, endoscopic, or surgical therapies such as cholecystectomy due to the onset of gallstone-related symptoms or gallstone-related complications. Thus, patients with symptomatic, uncomplicated or complicated gallstones, regardless of the type of stones, represent one of the largest patient categories admitted to European hospitals. This review deals with the important critical care aspects associated with a gallstone-related disease.
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Affiliation(s)
- Piero Portincasa
- Clinica Medica "A. Murri", Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
- Piero Portincasa, Clinica Medica “Augusto Murri”, Department of Biomedical Sciences and Human Oncology, University of Bari Medical School - Piazza Giulio Cesare 11; 70124 Bari – Italy
| | - Emilio Molina-Molina
- Clinica Medica "A. Murri", Department of Biomedical Sciences & Human Oncology, University of Bari Medical School, Bari, Italy
| | - Gabriella Garruti
- Section of Endocrinology, Department of Emergency and Organ Transplantations, University of Bari "Aldo Moro" Medical School, Piazza G. Cesare 11, 70124Bari, Italy
| | - David Q.-H. Wang
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, "Albert Einstein" College of Medicine, Bronx, NY 10461, USA
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15
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Ridtitid W, Kulpatcharapong S, Piyachaturawat P, Angsuwatcharakon P, Kongkam P, Rerknimitr R. The impact of empiric endoscopic biliary sphincterotomy on future gallstone-related complications in patients with non-severe acute biliary pancreatitis whose cholecystectomy was deferred or not performed. Surg Endosc 2018; 33:3325-3333. [PMID: 30535937 DOI: 10.1007/s00464-018-06622-9] [Citation(s) in RCA: 4] [Impact Index Per Article: 0.7] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/20/2018] [Accepted: 12/04/2018] [Indexed: 10/27/2022]
Abstract
BACKGROUND Early cholecystectomy (EC) is recommended in patients with acute biliary pancreatitis (ABP). In real-life practice, cholecystectomy is frequently deferred due to various reasons and delayed cholecystectomy (DC) is performed instead. Endoscopic sphincterotomy (ES) is an alternative to prevent recurrent pancreatitis, however other gallstone-related complications (GCs) may still develop. We aimed to determine the impact of ES on future GCs in patients with non-severe acute biliary pancreatitis whose cholecystectomy was deferred or not performed. METHODS During 2006-2016, we included patients with non-severe ABP while those with severe pancreatitis and concurrent cholangitis were excluded. GC events were compared between those who had DC with ES and those who had DC without ES. A similar comparison was made in patients with and without ES who did not receive cholecystectomy. RESULTS Of 266 patients with ABP, non-severe ABP was identified in 146. Only 16 (11%) had EC. Of patients with non-severe ABP who underwent DC (n = 88), recurrent ABP in the ES group was lower than those from the non-ES group (2% vs. 17%; p = 0.01). Acute cholecystitis was found in 0%, 6% and 10% of patients with EC, DC and those without cholecystectomy (p = 0.39). Of those who did not undergo cholecystectomy (n = 42), recurrent ABP in the ES group was still lower than the non-ES group (4% vs. 36%; p = 0.006). ES related complications were mild pancreatitis (4%) and post sphincterotomy bleeding (5%). CONCLUSIONS In patient with non-severe ABP, ES is an alternative to reduce recurrent ABP, however without EC, future cholecystitis may still develop.
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Affiliation(s)
- Wiriyaporn Ridtitid
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Santi Kulpatcharapong
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Panida Piyachaturawat
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Phonthep Angsuwatcharakon
- Department of Anatomy, Faculty of Medicine, Chulalongkorn University, Bangkok, 10400, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Pradermchai Kongkam
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand.,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand
| | - Rungsun Rerknimitr
- Department of Medicine, Faculty of Medicine, Chulalongkorn University, Bangkok, 10330, Thailand. .,Excellence Center in GI Endoscopy, King Chulalongkorn Memorial Hospital, Bangkok, 10330, Thailand.
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16
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Wang HH, Portincasa P, Liu M, Tso P, Wang DQH. Similarities and differences between biliary sludge and microlithiasis: Their clinical and pathophysiological significances. LIVER RESEARCH 2018; 2:186-199. [PMID: 34367716 PMCID: PMC8341470 DOI: 10.1016/j.livres.2018.10.001] [Citation(s) in RCA: 8] [Impact Index Per Article: 1.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
The terms biliary sludge and cholesterol microlithiasis (hereafter referred to as microlithiasis) were originated from different diagnostic techniques and may represent different stages of cholesterol gallstone disease. Although the pathogenesis of biliary sludge and microlithiasis may be similar, microlithiasis could be preceded by biliary sludge, followed by persistent precipitation and aggregation of solid cholesterol crystals, and eventually, gallstone formation. Many clinical conditions are clearly associated with the formation of biliary sludge and microlithiasis, including total parenteral nutrition, rapid weight loss, pregnancy, organ transplantation, administration of certain medications, and a variety of acute and chronic illnesses. Numerous studies have demonstrated complete resolution of biliary sludge in approximately 40% of patients, a cyclic pattern of disappearing and reappearing in about 40%, and progression to gallstones in nearly 20%. Although only a minority of patients with ultrasonographic demonstration of biliary sludge develop gallstones, it is still a matter of controversy whether microlithiasis could eventually evolve to cholesterol gallstones. Biliary sludge and microlithiasis are asymptomatic in the vast majority of patients; however, they can cause biliary colic, acute cholecystitis, and acute pancreatitis. Biliary sludge and microlithiasis are most often diagnosed ultrasonographically and bile microscopy is considered the gold standard for their diagnosis. Specific measures to prevent the development of biliary sludge are not practical or cost-effective in the general population. Laparoscopic cholecystectomy offers the most definitive therapy on biliary sludge. Endoscopic sphincterotomy or surgical intervention is effective for microlithiasis-induced pancreatitis. Ursodeoxycholic acid can effectively prevent the recurrence of solid cholesterol crystals and significantly reduce the risk of recurrent pancreatitis.
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Affiliation(s)
- Helen H. Wang
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, Albert Einstein College of Medicine, Bronx, NY, USA
| | - Piero Portincasa
- Department of Biomedical Sciences and Human Oncology, Clinica Medica “A. Murri”, University of Bari “Aldo Moro” Medical School, Bari, Italy
| | - Min Liu
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - Patrick Tso
- Department of Pathology and Laboratory Medicine, University of Cincinnati College of Medicine, Cincinnati, OH, USA
| | - David Q.-H. Wang
- Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, Albert Einstein College of Medicine, Bronx, NY, USA,Corresponding author. Department of Medicine, Division of Gastroenterology and Liver Diseases, Marion Bessin Liver Research Center, Albert Einstein College of Medicine, Bronx, NY, USA., (D.Q.-H. Wang)
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17
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Lyu YX, Cheng YX, Jin HF, Jin X, Cheng B, Lu D. Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis. BMC Surg 2018; 18:111. [PMID: 30486807 PMCID: PMC6263067 DOI: 10.1186/s12893-018-0445-9] [Citation(s) in RCA: 23] [Impact Index Per Article: 3.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 07/13/2018] [Accepted: 11/08/2018] [Indexed: 12/11/2022] Open
Abstract
BACKGROUND The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP). METHODS We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom). RESULTS This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78-1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67-1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42-3.86; p = 0.66), or OT (RR = 1.57; 95% CI, - 1.58-4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = - 2.08; 95% CI, - 3.17 to - 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = - 0.40; 95% CI, - 0.80-0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%). CONCLUSION This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.
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Affiliation(s)
- Yun-Xiao Lyu
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Yun-Xiao Cheng
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Hang-Fei Jin
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Xin Jin
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Bin Cheng
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
| | - Dian Lu
- Department of Hepatobiliary Surgery, Dongyang People’s Hospital, 60 West Wuning Road, 322100, Dongyang, Zhejiang, China
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18
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Abstract
OBJECTIVES Few studies have evaluated national readmission rates after acute pancreatitis (AP) in the United States. We sought to evaluate modifiable factors impacting 30-day readmissions after AP hospitalizations. METHODS We used the Nationwide Readmission Database (2013) involving all adults with a primary discharge diagnosis of AP. Multivariable logistic regression models assessed independent predictors for specific outcomes. RESULTS Among 180,480 patients with AP index admissions, 41,094 (23%) had biliary AP, of which 10.5% were readmitted within 30 days. The 30-day readmission rate for patients who underwent same-admission cholecystectomy (CCY) was 6.5%, compared with 15.1% in those who did not (P < 0.001). Failure of index admission CCY increased the risk of readmissions (odds ratio [OR], 2.27; 95% confidence interval [CI], 2.04-2.56). Same-admission CCY occurred in 55% (n = 19,274) of patients without severe AP. Severe AP (OR, 0.73; 95% CI, 0.65-0.81), sepsis (OR, 0.63; 95% CI, 0.52-0.75), 3 or more comorbidities (OR, 0.74; 95% CI, 0.68-0.79), and admissions to small (OR, 0.76; 95% CI, 0.64-0.91) or rural (OR, 0.78; 95% CI, 0.65-0.95) hospitals were less likely to undergo same-admission CCY. CONCLUSIONS Same-admission CCY should be considered in patients with biliary AP when feasible. This national appraisal recognizes modifiable risk factors to reduce readmission in biliary AP and reinforces adherence to major society guidelines.
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19
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da Costa DW, Schepers NJ, Bouwense SA, Hollemans BA, Doorakkers E, Boerma D, Rosman C, Dejong CH, Spanier MBW, van Santvoort HC, Gooszen HG, Besselink MG. Colicky pain and related complications after cholecystectomy for mild gallstone pancreatitis. HPB (Oxford) 2018; 20:745-751. [PMID: 29602557 DOI: 10.1016/j.hpb.2018.02.638] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 12/07/2017] [Revised: 02/14/2018] [Accepted: 02/24/2018] [Indexed: 12/12/2022]
Abstract
BACKGROUND Same-admission cholecystectomy is advised after gallstone pancreatitis to prevent recurrent pancreatitis, colicky pain and other complications, but data on the incidence of symptoms and complications after cholecystectomy are lacking. METHODS This was a prospective cohort study during the previously published randomized controlled PONCHO trial on timing of cholecystectomy after mild gallstone pancreatitis. Data on healthcare consumption and questionnaires focusing on colicky pain and biliary complications were obtained during 6 months after cholecystectomy. Main outcomes were (i) postoperative colicky pain as reported in questionnaires and (ii) medical treatment for postoperative symptoms and gallstone related complications. RESULTS Among 262 patients who underwent cholecystectomy after mild gallstone pancreatitis, 28 of 191 patients (14.7%) reported postoperative colicky pain. The majority of these were reported within 2 months after surgery and were single events. Overall, 25 patients (9.5%) required medical treatment for symptoms or gallstone related complications. Acute readmission was required in seven patients (2.7%). No predictors for the development of postoperative colicky pain were identified. DISCUSSION Some 15% of patients experienced colicky pain after cholecystectomy for mild gallstone pancreatitis, which were mostly single events and rarely required readmission. These data may be used to better inform patients undergoing cholecystectomy for mild gallstone pancreatitis.
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Affiliation(s)
- David W da Costa
- Department of Radiology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Nicolien J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - Stefan A Bouwense
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Bob A Hollemans
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Eva Doorakkers
- Upper Gastrointestinal Surgery, Department of Molecular Medicine and Surgery, Karolinksa Institutet, Stockholm, Sweden
| | - Djamila Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - Camiel Rosman
- Department of Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Cees H Dejong
- Department of Surgery, Maastricht University Medical Centre, The Netherlands
| | - Marcel B W Spanier
- Department of Gastroenterology, Rijnstate Hospital, Arnhem, The Netherlands
| | | | - Hein G Gooszen
- Department of Operating Theatres and Evidence Based Surgery, Radboud University Medical Center, Nijmegen, The Netherlands
| | - Marc G Besselink
- Department of Surgery, Amsterdam Gastroenterology and Metabolism, Academic Medical Center, University of Amsterdam, The Netherlands.
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20
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Abstract
OBJECTIVE This study aimed to develop a diagnostic model that predicts acute pancreatitis (AP) risk before imaging. METHODS Emergency department patients with serum lipase elevated to 3 times the upper limit of normal or greater were identified retrospectively (September 1, 2013-August 31, 2015). An AP diagnosis was established by expert review of full hospitalization records. Candidate predictors included demographic and clinical characteristics at presentation. Using a derivation set, a multivariable logistic regression model and corresponding point-based scoring system was developed to predict AP. Discrimination accuracy and calibration were assessed in a separate validation set. RESULTS In 319 eligible patients, 182 (57%) had AP. The final model (area under curve, 0.92) included 8 predictors: number of prior AP episodes; history of cholelithiasis; no abdominal surgery (prior 2 months); time elapsed from symptom onset; pain localized to epigastrium, of progressively worsening severity, and severity level at presentation; and extent of lipase elevation. At a diagnostic risk threshold of 8 points or higher (≥99%), the model identified AP with a sensitivity of 45%, and a specificity and a positive predictive value of 100%. CONCLUSIONS In emergency department patients with lipase elevated to 3 times the upper limit of normal or greater, this model helps identify AP risk before imaging. Prospective validation studies are needed to confirm diagnostic accuracy.
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21
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Mallick B, Shrama DJ, Siddappa P, Dhaka N, Malik S, Sinha SK, Yadav TD, Gupta V, Kochhar R. Differences between the outcome of recurrent acute pancreatitis and acute pancreatitis. JGH OPEN 2018; 2:134-138. [PMID: 30483578 PMCID: PMC6207058 DOI: 10.1002/jgh3.12060] [Citation(s) in RCA: 7] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 03/16/2018] [Revised: 04/20/2018] [Accepted: 05/08/2018] [Indexed: 12/29/2022]
Abstract
Background and aim Overall, a handful of studies are available on the outcomes of recurrent acute pancreatitis (RAP), in comparison to the first episode of acute pancreatitis (AP). We aimed to provide a more complete and updated picture of RAP and how it is different from the initial episode of AP. Methods Consecutive patients admitted with an episode of AP over 8 years were divided into two groups on the basis of prior episodes: AP and RAP. Primary outcome measures were for surgical necrosectomy and mortality. Results Of the 724 patients (age 39.22 ± 13.25 years, 68% male) with an episode of pancreatitis, 632 (87.3%) had presented with a first episode (AP) and 92 (12.7%) with at least one prior episode (RAP). The incidence of severe pancreatitis was significantly less in RAP patients (10.9%) in comparison to AP patients (48.6%). The requirement of surgical intervention and mortality were less in patients with RAP (1.1 and 2.2%, respectively) compared to patients with AP (9.3 and 18%, respectively). The mean number of episodes per RAP patients was 2.97 ± 1.66 (range 2–10), and 64.1% had only two episodes. Regarding the etiology of RAP patients, biliary etiology (32.6%) and alcohol (30.4%) were the two most frequent factors, and no etiology could be identified in 19.6%. Conclusion Patients with RAP had milder disease course and lesser mortality when compared to the initial episode of AP. Appropriate evaluation and dealing with etiological factors at the initial episode of AP can prevent a majority of RAP.
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Affiliation(s)
- Bipadabhanjan Mallick
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Dibya J Shrama
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Pradeep Siddappa
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Narendra Dhaka
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Sarthak Malik
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Saroj K Sinha
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Thakur D Yadav
- Department of General Surgery Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Vikas Gupta
- Department of General Surgery Postgraduate Institute of Medical Education and Research Chandigarh India
| | - Rakesh Kochhar
- Department of Gastroenterology Postgraduate Institute of Medical Education and Research Chandigarh India
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22
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Occhipinti V, Segato S, Carrara A, Orlando S, Conte D. ERCP or NO ERCP: the case report of a frail patient. Intern Emerg Med 2018; 13:367-371. [PMID: 28875255 DOI: 10.1007/s11739-017-1732-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 07/03/2017] [Accepted: 08/04/2017] [Indexed: 10/18/2022]
Affiliation(s)
- Vincenzo Occhipinti
- Gastroenterology and Endoscopy Unit, Università degli Studi Milan, Milan, Italy
| | - Simone Segato
- Gastroenterology and Endoscopy Unit, Università degli Studi Milan, Milan, Italy
| | - Alberto Carrara
- General and Emergency Surgery, Università degli Studi Milan, Milan, Italy
| | - Stefania Orlando
- Gastroenterology and Endoscopy Unit, Università degli Studi Milan, Milan, Italy
| | - Dario Conte
- Gastroenterology and Endoscopy Unit, Università degli Studi Milan, Milan, Italy.
- Fondazione IRCCS Cà Granda, Ospedale Maggiore Policlinico Milan, Università degli Studi Milan, Via F. Sforza, 35, 20122, Milan, Italy.
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23
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Yang DJ, Lu HM, Guo Q, Lu S, Zhang L, Hu WM. Timing of Laparoscopic Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review and Meta-Analysis. J Laparoendosc Adv Surg Tech A 2017; 28:379-388. [PMID: 29271689 DOI: 10.1089/lap.2017.0527] [Citation(s) in RCA: 16] [Impact Index Per Article: 2.3] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 02/06/2023] Open
Abstract
AIM To compare the safety of cholecystectomy in early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC). METHODS We systematically searched PubMed, EMBASE, and Cochrane Library for studies that were published from January 1992 to March 2017. We included studies on patients with mild biliary pancreatitis and that reported the timing of cholecystectomy and the number of complications, readmissions, and conversion to open cholecystectomy. Moreover, we assessed the quality and bias risks of the included studies. RESULTS After screening 4651 studies, we included 3 randomized clinical trials and 10 retrospective studies. The included studies described 2291 patients, of whom 1141 (49.8%) underwent ELC and 1150 (50.2%) underwent DLC. The reported rate of complications for ELC (6.8%) was lower than that for DLC (13.45%). The reported rate of readmission for ELC was lower than that for DLC. The length of hospital stay was longer with DLC than with ELC. ELC and DLC did not have significantly different rates of conversion to open cholecystectomy and duration of surgery. CONCLUSION This meta-analysis provides evidence that ELC is better than DLC in many aspects for acute mild pancreatitis patients undergoing laparoscopic cholecystectomy. ELC associated with few complications and readmissions, as well as a short length of hospital stay.
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Affiliation(s)
- Du-Jiang Yang
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Hui-Min Lu
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Qiang Guo
- 2 Department of Vascular Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Shan Lu
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Ling Zhang
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
| | - Wei-Ming Hu
- 1 Department of Pancreatic Surgery, West China Hospital, Sichuan University , Chengdu, China
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24
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Williams E, Beckingham I, El Sayed G, Gurusamy K, Sturgess R, Webster G, Young T. Updated guideline on the management of common bile duct stones (CBDS). Gut 2017; 66:765-782. [PMID: 28122906 DOI: 10.1136/gutjnl-2016-312317] [Citation(s) in RCA: 221] [Impact Index Per Article: 31.6] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 05/25/2016] [Revised: 12/08/2016] [Accepted: 12/15/2016] [Indexed: 02/06/2023]
Abstract
Common bile duct stones (CBDS) are estimated to be present in 10-20% of individuals with symptomatic gallstones. They can result in a number of health problems, including pain, jaundice, infection and acute pancreatitis. A variety of imaging modalities can be employed to identify the condition, while management of confirmed cases of CBDS may involve endoscopic retrograde cholangiopancreatography, surgery and radiological methods of stone extraction. Clinicians are therefore confronted with a number of potentially valid options to diagnose and treat individuals with suspected CBDS. The British Society of Gastroenterology first published a guideline on the management of CBDS in 2008. Since then a number of developments in management have occurred along with further systematic reviews of the available evidence. The following recommendations reflect these changes and provide updated guidance to healthcare professionals who are involved in the care of adult patients with suspected or proven CBDS. It is not a protocol and the recommendations contained within should not replace individual clinical judgement.
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Affiliation(s)
- Earl Williams
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Ian Beckingham
- HPB Service, Nottingham University Hospitals NHS Trust, Nottingham, UK
| | - Ghassan El Sayed
- Bournemouth Digestive Diseases Centre, Royal Bournemouth and Christchurch NHS Hospital Trust, Bournemouth, UK
| | - Kurinchi Gurusamy
- Department of Surgery, University College London Medical School, London, UK
| | - Richard Sturgess
- Aintree Digestive Diseases Unit, Aintree University Hospital Liverpool, Liverpool, UK
| | - George Webster
- Department of Hepatopancreatobiliary Medicine, University College Hospital, London, UK
| | - Tudor Young
- Department of Radiology, The Princess of Wales Hospital, Bridgend, UK
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25
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Abdelaal A, El-Matbouly M, Sulieman I, Elfaki A, El-Bakary T, Abdelaziem S, Gehani S, Toro A, Di Carlo I. Role of intraoperative cholangiography for detecting residual stones after biliary pancreatitis: still useful? A retrospective study. World J Emerg Surg 2017; 12:18. [PMID: 28428811 PMCID: PMC5397714 DOI: 10.1186/s13017-017-0130-9] [Citation(s) in RCA: 3] [Impact Index Per Article: 0.4] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/15/2017] [Accepted: 04/13/2017] [Indexed: 12/30/2022] Open
Abstract
Background Intraoperative cholangiography (IOC) may detect residual stones in the common bile duct (CBD) after acute biliary pancreatitis (ABP). The aim of the present study is to analyze the utility of IOC in detecting residual stones in patients undergoing cholecystectomy for ABP and if complications are related with this procedure. Methods Demographic and clinical factors were assessed in patients with mild ABP who underwent IOC during laparoscopic cholecystectomy. Factors assessed included preoperative size of the CBD on ultrasonography, presence of stones in the gallbladder and the CBD, and IOC results. For the statistical analysis, χ2 or Fisher’s exact tests to compare proportions and the nonparametric Mann–Whitney U test for analysis of values with abnormal distribution were used. Results The study included 113 patients, 82 males (72.6%) and 31 females (27.4%), of mean age 46.9 ± 14.7 years (range 18–86 years). All preoperative laboratory indicators were elevated. The group of the patients with stones in the CBD diagnosed by IOC was divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD diagnosed preoperatively with ultrasound. The laboratory tests do not demonstrate difference statistically significative between these two groups. The group of the patients without stones in the CBD diagnosed by IOC was also divided in patients with diameters <0.8 mm and with diameters ≥0.8 mm of the CBD. Also in these two groups, the statistical analysis of the laboratory tests does not demonstrate significative difference. Most procedures were performed by specialists (64.6%), and all patients underwent IOC. IOC showed stones in 84/113 patients (74.3%). A comparison of patients with and without stones at IOC showed similar mean times from hospitalization to surgery (5.9 days [range 2–12 days] vs. 6.1 days [range 2–23 days]), from surgery until hospital discharge (2.0 days [range 0–4 days] vs. 2.2 days [range 0–11 days]), and overall length of stay (7.9 days [range 3–19 days] vs. 8.3 days [range 3–23 days]) (P > 0.001). Conclusions IOC is useful to diagnose residual CBD stones, without increasing complications related to the procedure itself.
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Affiliation(s)
- Abdelrahman Abdelaal
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Moamena El-Matbouly
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Ibnouf Sulieman
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Ahmad Elfaki
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Tamer El-Bakary
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Sherif Abdelaziem
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Salahdin Gehani
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar
| | - Adriana Toro
- Department of Surgery, Barone Romeo Hospital, via Mazzini 14, 98066 Patti, (ME) Italy
| | - Isidoro Di Carlo
- Department of General Surgery, Hamad General Hospital, Al Rayyan Road, 3050 Doha, Qatar.,Department of Surgical Sciences and Advanced Technologies "G.F. Ingrassia", University of Catania, Via Santa Sofia 78, 95100 Catania, Italy
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26
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Kamal A, Akhuemonkhan E, Akshintala VS, Singh VK, Kalloo AN, Hutfless SM. Effectiveness of Guideline-Recommended Cholecystectomy to Prevent Recurrent Pancreatitis. Am J Gastroenterol 2017; 112:503-510. [PMID: 28071655 DOI: 10.1038/ajg.2016.583] [Citation(s) in RCA: 21] [Impact Index Per Article: 3.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/08/2016] [Accepted: 11/02/2016] [Indexed: 12/11/2022]
Abstract
OBJECTIVES Cholecystectomy during or within 4 weeks of hospitalization for acute biliary pancreatitis is recommended by guidelines. We examined adherence to the guidelines for incident mild-to-moderate acute biliary pancreatitis and the effectiveness of cholecystectomy to prevent recurrent episodes of pancreatitis. METHODS Individuals in the 2010-2013 MarketScan Commercial Claims & Encounters database with a hospitalization associated with International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes of 577.0 for acute pancreatitis and 574.x for gallstone disease were eligible. Guideline adherence was considered cholecystectomy within 30 days of the first/index hospitalization for biliary pancreatitis. Individuals with and without guideline-adherent cholecystectomy were compared for subsequent hospitalization for acute or chronic pancreatitis using a Cox proportional hazards model adjusted for age, sex, comorbidities, and length of index hospital stay. RESULTS Of the 17,010 patients who met the inclusion criteria, 78% were adherent with the guidelines, including 10,918 who underwent cholecystectomy during the index hospitalization and 2,387 who underwent cholecystectomy within 30 days. Among 3,705 patients non-adherent with the guidelines, 1,213 had a cholecystectomy 1-6 months after the index hospitalization. Guideline-adherent cholecystectomy resulted in fewer subsequent hospitalizations for acute and chronic pancreatitis as compared with non-adherence to the guidelines (acute pancreatitis: 3% vs. 13%, P<0.001; chronic pancreatitis: 1% vs. 4%, P<0.001). CONCLUSIONS Nearly four out of five patients underwent cholecystectomy for acute biliary pancreatitis in a timeframe, consistent with guidelines. Adherence resulted in a decrease in subsequent hospitalizations for both acute and chronic pancreatitis. However, the majority of non-adherent patients did not undergo a subsequent cholecystectomy. There may be factors that predict the need for immediate vs. delayed cholecystectomy.
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Affiliation(s)
- Ayesha Kamal
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Eboselume Akhuemonkhan
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Venkata S Akshintala
- Department of Medicine, University of Pittsburgh Medical Center, Pittsburgh, Pennsylvania, USA
| | - Vikesh K Singh
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Anthony N Kalloo
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA
| | - Susan M Hutfless
- Department of Medicine, Division of Gastroenterology and Hepatology, Johns Hopkins University, Baltimore, Maryland, USA.,Department of Epidemiology, Johns Hopkins Bloomberg School of Public Health, Baltimore, Maryland, USA
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27
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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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28
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Dedemadi G, Nikolopoulos M, Kalaitzopoulos I, Sgourakis G. Management of patients after recovering from acute severe biliary pancreatitis. World J Gastroenterol 2016; 22:7708-7717. [PMID: 27678352 PMCID: PMC5016369 DOI: 10.3748/wjg.v22.i34.7708] [Citation(s) in RCA: 12] [Impact Index Per Article: 1.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Download PDF] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 03/26/2016] [Revised: 06/07/2016] [Accepted: 06/15/2016] [Indexed: 02/06/2023] Open
Abstract
Cholelithiasis is the most common cause of acute pancreatitis, accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned, the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management, including cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process, usually not earlier than 6 wk after onset of acute pancreatitis, seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed, but if used for definitive treatment, they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques, if not therapeutic, can be used as a bridge to definitive operative treatment, which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.
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29
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Greenberg JA, Hsu J, Bawazeer M, Marshall J, Friedrich JO, Nathens A, Coburn N, May GR, Pearsall E, McLeod RS. Clinical practice guideline: management of acute pancreatitis. Can J Surg 2016; 59:128-40. [PMID: 27007094 DOI: 10.1503/cjs.015015] [Citation(s) in RCA: 196] [Impact Index Per Article: 24.5] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 12/11/2022] Open
Abstract
ABSTRACT There has been an increase in the incidence of acute pancreatitis reported worldwide. Despite improvements in access to care, imaging and interventional techniques, acute pancreatitis continues to be associated with significant morbidity and mortality. Despite the availability of clinical practice guidelines for the management of acute pancreatitis, recent studies auditing the clinical management of the condition have shown important areas of noncompliance with evidence-based recommendations. This underscores the importance of creating understandable and implementable recommendations for the diagnosis and management of acute pancreatitis. The purpose of the present guideline is to provide evidence-based recommendations for the management of both mild and severe acute pancreatitis as well as the management of complications of acute pancreatitis and of gall stone-induced pancreatitis.
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Affiliation(s)
- Joshua A Greenberg
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jonathan Hsu
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Mohammad Bawazeer
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - John Marshall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Jan O Friedrich
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Avery Nathens
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Natalie Coburn
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Gary R May
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Emily Pearsall
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
| | - Robin S McLeod
- From the Department of Surgery, University of Toronto, Toronto, Ont. (Greenberg, Bawazeer, Nathens, Coburn, Pearsall, McLeod); the Department of Medicine, University of Toronto, Toronto, Ont. (Hsu, Friedrich, May); the Department of Health Policy, Management and Evaluation, University of Toronto, Toronto, Ont. (McLeod); the Interdepartmental Division of Critical Care, University of Toronto, Toronto, Ont. (Bawazeer, Friedrich); the Division of General Surgery, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Zane Cohen Centre for Digestive Diseases, Mount Sinai Hospital, Toronto, Ont. (Hsu, Pearsall, McLeod); the Samuel Lunenfeld Research Institute, Mount Sinai Hospital, Toronto, Ont. (McLeod); the Division of General Surgery, Sunnybrook Health Sciences Centre, Toronto, Ont. (Nathens, Coburn); and the Divisions of Gastroenterology and General Surgery (Marshall) and Critical Care (Friedrich), St. Michael's Hospital, Toronto, Ont
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Management of acute pancreatitis (AP) - Polish Pancreatic Club recommendations. GASTROENTEROLOGY REVIEW 2016; 11:65-72. [PMID: 27350832 PMCID: PMC4916242 DOI: 10.5114/pg.2016.60251] [Citation(s) in RCA: 7] [Impact Index Per Article: 0.9] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Subscribe] [Scholar Register] [Received: 05/15/2016] [Accepted: 05/22/2016] [Indexed: 12/16/2022]
Abstract
The presented recommendations concern the current management of acute pancreatitis. The recommendations relate to the diagnostics and treatment of early and late phases of acute pancreatitis and complications of the disease taking into consideration surgical and endoscopic methods. All the recommendations were subjected to voting by the members of the Working Group of the Polish Pancreatic Club, who evaluated them every single time on a five-point scale, where A means full acceptance, B means acceptance with a certain reservation, C means acceptance with a serious reservation, D means rejection with a certain reservation and E means full rejection. The results of the vote, together with commentary, are provided for each recommendation.
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Compliance with Evidence-Based Guidelines in Acute Pancreatitis: an Audit of Practices in University of Toronto Hospitals. J Gastrointest Surg 2016; 20:392-400. [PMID: 26621675 DOI: 10.1007/s11605-015-3023-9] [Citation(s) in RCA: 22] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/05/2015] [Accepted: 11/05/2015] [Indexed: 01/31/2023]
Abstract
Despite existing evidence-based practice guidelines for the management of acute pancreatitis, clinical compliance with recommendations is poor. We conducted a retrospective review of 248 patients admitted between 2010 and 2012 with acute pancreatitis at eight University of Toronto affiliated hospitals. We included all patients admitted to ICU (52) and 25 ward patients from each site (196). Management was compared with the most current evidence used in the Best Practice in General Surgery Management of Acute Pancreatitis Guideline. Fifty-six patients (22.6 %) had only serum lipase tested for biochemical diagnosis. Admission ultrasound was performed in 174 (70.2 %) patients, with 69 (27.8 %) undergoing ultrasound and CT. Of non-ICU patients, 158 (80.6 %) were maintained nil per os, and only 18 (34.6 %) ICU patients received enteral nutrition, commencing an average 7.5 days post-admission. Fifty (25.5 %) non-ICU patients and 25 (48.1 %) ICU patients received prophylactic antibiotics. Only 24 patients (22.6 %) with gallstone pancreatitis underwent index admission cholecystectomy. ERCP with sphincterotomy was under-utilized among patients with biliary obstruction (16 [31 %]) and candidates for prophylactic sphincterotomy (18 [22 %]). Discrepancies exist between the most current evidence and clinical practice within the University of Toronto hospitals. A guideline, knowledge translation strategy, and assessment of barriers to clinical uptake are required to change current clinical practice.
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Bejarano González N, Romaguera Monzonís A, García Borobia FJ, García Monforte N, Serra Plà S, Rebasa Cladera P, Flores Clotet R, Navarro Soto S. Influence of delayed cholecystectomy after acute gallstone pancreatitis on recurrence. Consequences of lack of resources. REVISTA ESPANOLA DE ENFERMEDADES DIGESTIVAS 2016; 108:117-22. [DOI: 10.17235/reed.2016.4086/2015] [Citation(s) in RCA: 6] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Track Full Text] [Subscribe] [Scholar Register] [Indexed: 11/20/2022]
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Portincasa P, Di Ciaula A, de Bari O, Garruti G, Palmieri VO, Wang DQH. Management of gallstones and its related complications. Expert Rev Gastroenterol Hepatol 2016; 10:93-112. [PMID: 26560258 DOI: 10.1586/17474124.2016.1109445] [Citation(s) in RCA: 42] [Impact Index Per Article: 5.3] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/05/2023]
Abstract
The majority of gallstone patients remain asymptomatic; however, interest toward the gallstone disease is continuing because of the high worldwide prevalence and management costs and the development of gallstone symptoms and complications. For cholesterol gallstone disease, moreover, a strong link exists between this disease and highly prevalent metabolic disorders such as obesity, dyslipidemia, type 2 diabetes, hyperinsulinemia, hypertriglyceridemia and the metabolic syndrome. Information on the natural history as well as the diagnostic, surgical (mainly laparoscopic cholecystectomy) and medical tools available to facilitate adequate management of cholelithiasis and its complications are, therefore, crucial to prevent the negative outcomes of gallstone disease. Moreover, some risk factors for gallstone disease are modifiable and some preventive strategies have become necessary to reduce the onset and the severity of complications.
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Affiliation(s)
- P Portincasa
- a Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri" , University of Bari Medical School , Bari , Italy
| | - A Di Ciaula
- b Division of Internal Medicine , Hospital of Bisceglie , Bisceglie , Italy
| | - O de Bari
- a Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri" , University of Bari Medical School , Bari , Italy
- d Department of Internal Medicine, Division of Gastroenterology and Hepatology , Saint Louis University School of Medicine , St. Louis , MO , USA
| | - G Garruti
- c Department of Emergency and Organ Transplants, Section of Endocrinology, Andrology and Metabolic Diseases , University of Bari Medical School , Bari , Italy
| | - V O Palmieri
- a Department of Biomedical Sciences and Human Oncology, Clinica Medica "A. Murri" , University of Bari Medical School , Bari , Italy
| | - D Q-H Wang
- d Department of Internal Medicine, Division of Gastroenterology and Hepatology , Saint Louis University School of Medicine , St. Louis , MO , USA
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da Costa DW, Schepers NJ, Römkens TEH, Boerma D, Bruno MJ, Bakker OJ. Endoscopic sphincterotomy and cholecystectomy in acute biliary pancreatitis. Surgeon 2015; 14:99-108. [PMID: 26542765 DOI: 10.1016/j.surge.2015.10.002] [Citation(s) in RCA: 11] [Impact Index Per Article: 1.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 06/17/2015] [Revised: 10/05/2015] [Accepted: 10/06/2015] [Indexed: 02/07/2023]
Abstract
BACKGROUND This review discusses current insights with regard to biliary tract management during and after acute biliary pancreatitis. METHODS A MEDLINE and EMBASE search was done and studies were selected based on methodological quality and publication date. The recommendations of recent guidelines are incorporated in this review. In absence of consensus in the literature, expert opinion is expressed. RESULTS There is no role for early endoscopic retrograde cholangiopancreatography (ERCP) in patients with (predicted) mild biliary pancreatitis to improve outcome. In case of persisting choledocholithiasis, ERCP with stone extraction is scheduled electively when the acute event has subsided. Whether early ERCP with sphincterotomy is beneficial in patients with predicted severe pancreatitis remains subject to debate. Regardless of disease severity, in case of concomitant cholangitis urgent endoscopic sphincterotomy (ES) is recommended. As a definitive treatment to reduce the risk of recurrent biliary events in the long term, ES is inferior to cholecystectomy and should be reserved for patients considered unfit for surgery. After severe biliary pancreatitis, cholecystectomy should be postponed until all signs of inflammation have subsided. In patients with mild pancreatitis, cholecystectomy during the primary admission reduces the risk of recurrent biliary complications. CONCLUSION Recent research has provided valuable data to guide biliary tract management in the setting of acute biliary pancreatitis with great value and benefit for patients and clinicians. Some important clinical dilemmas remain, but it is anticipated that on-going clinical trials will deliver some important insights and additional guidance soon.
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Affiliation(s)
- D W da Costa
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - N J Schepers
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands; Department of Gastroenterology and Hepatology, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - T E H Römkens
- Department of Gastroenterology and Hepatology, Jeroen Bosch Hospital, 's-Hertogenbosch, The Netherlands
| | - D Boerma
- Department of Surgery, St. Antonius Hospital, Nieuwegein, The Netherlands
| | - M J Bruno
- Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands
| | - O J Bakker
- Department of Surgery, University Medical Center, Utrecht, The Netherlands.
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Martin JA. Incisionless stone extraction 2.0: clever, but costly. Gastrointest Endosc 2015; 82:724-7. [PMID: 26385280 DOI: 10.1016/j.gie.2015.06.032] [Citation(s) in RCA: 1] [Impact Index Per Article: 0.1] [Reference Citation Analysis] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/03/2015] [Accepted: 06/17/2015] [Indexed: 12/11/2022]
Affiliation(s)
- John A Martin
- Division of Gastroenterology and Hepatology, Mayo Clinic, Rochester, Minnesota, USA
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Validation and improvement of a proposed scoring system to detect retained common bile duct stones in gallstone pancreatitis. Surgery 2015; 157:1073-9. [PMID: 25712200 DOI: 10.1016/j.surg.2015.01.005] [Citation(s) in RCA: 25] [Impact Index Per Article: 2.8] [Reference Citation Analysis] [Abstract] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Revised: 11/11/2014] [Accepted: 01/11/2015] [Indexed: 02/06/2023]
Abstract
BACKGROUND In 2009, a study from our institution used retrospective data and multivariate analysis to identify 5 quantitative variables and their cutoffs that have a positive predictive value (PPV) for common bile duct (CBD) stones in gallstone pancreatitis. They also proposed a management protocol based on the scoring system. This prospective study sought to validate that scoring system. METHODS From October 2009 to August 2013, patients with gallstone pancreatitis were enrolled in the study. Scores of 0-5 were determined at admission, with 1 point for each criterion met: CBD ≥ 9 mm, gamma glutamyltransferase ≥ 350 U/L, alkaline phosphatase ≥ 250 U/L, total bilirubin ≥ 3 mg/dL, and direct bilirubin ≥ 2 mg/dL. All CBDs were assessed using intraoperative cholangiogram, MR cholangiopancreatography (MRCP), or endoscopic retrograde cholangiopancreatography (ERCP). RESULTS Of 84 patients, 16 had CBD stones. A score of 0 had negative predictive value (NPV) of 100% for CBD stones (P < .001). Scores of 1 and 2 had NPV of 81% and 83%, respectively. A score of 3 had NPV of 60%. A score of 4 had PPV of 67% (P = .002). A score of 5 had PPV of 100% (P < .001). The overall accuracy of the scoring system was 88%. CONCLUSION The scoring system is accurate in prediction of CBD stones in patients with gallstone pancreatitis. We propose that patients with 0 points undergo laparoscopic cholecystectomy, 1 and 2 points undergo laparoscopic cholecystectomy with intraoperative cholangiogram, 3 and 4 points undergo MRCP, and 5 points undergo ERCP as the first step in management for gallstone pancreatitis. The proposed protocol eliminated negative ERCPs.
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Bergman S, Al-Bader M, Sourial N, Vedel I, Hanna WC, Bilek AJ, Galatas C, Marek JE, Fraser SA. Recurrence of biliary disease following non-operative management in elderly patients. Surg Endosc 2015; 29:3485-90. [DOI: 10.1007/s00464-015-4098-9] [Citation(s) in RCA: 24] [Impact Index Per Article: 2.7] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 08/06/2014] [Accepted: 01/16/2015] [Indexed: 12/16/2022]
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Al-Qahtani HH. Early versus interval cholecystectomy after mild acute gallstone pancreatitis: A 10 year experience in central Saudi Arabia. J Taibah Univ Med Sci 2014. [DOI: 10.1016/j.jtumed.2014.06.001] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Indexed: 11/24/2022] Open
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Abstract
Gallstone disease is the most common cause of acute pancreatitis in the Western world. In most cases, gallstone pancreatitis is a mild and self-limiting disease, and patients may proceed without complications to cholecystectomy to prevent future recurrence. Severe disease occurs in about 20% of cases and is associated with significant mortality; meticulous management is critical. A thorough understanding of the disease process, diagnosis, severity stratification, and principles of management is essential to the appropriate care of patients presenting with this disease. This article reviews these topics with a focus on surgical management, including appropriate timing and choice of interventions.
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Affiliation(s)
- Daniel Cucher
- Department of Surgery, College of Medicine, University of Arizona, PO Box 245005, Tucson, AZ 85724, USA
| | - Narong Kulvatunyou
- Division of Acute Care Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245063, Tucson, AZ 85724-5063, USA
| | - Donald J Green
- Division of Acute Care Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245063, Tucson, AZ 85724-5063, USA
| | - Tun Jie
- Division of Hepatobiliary Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245066, Tucson, AZ 85724, USA
| | - Evan S Ong
- Division of Hepatobiliary Surgery, Department of Surgery, Arizona Health Sciences Center, University of Arizona, 1501 North Campbell Avenue, PO Box 245066, Tucson, AZ 85724, USA.
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Johnstone M, Marriott P, Royle TJ, Richardson CE, Torrance A, Hepburn E, Bhangu A, Patel A, Bartlett DC, Pinkney TD. The impact of timing of cholecystectomy following gallstone pancreatitis. Surgeon 2013; 12:134-40. [PMID: 24210949 DOI: 10.1016/j.surge.2013.07.006] [Citation(s) in RCA: 35] [Impact Index Per Article: 3.2] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 05/20/2013] [Revised: 07/23/2013] [Accepted: 07/24/2013] [Indexed: 02/06/2023]
Abstract
INTRODUCTION Current guidelines for the management of acute gallstone pancreatitis recommend cholecystectomy as definitive treatment during primary admission or within 2 weeks of discharge, with the aim of preventing recurrent pancreatitis. However, cholecystectomy during the inflammatory phase may increase surgical complication rates. This study aimed to determine whether adherence to the guidelines prevents recurrent pancreatitis while minimising surgical complications. METHODS Multi-centre review of seven UK hospitals, indentifying patients presenting with their first episode of gallstone pancreatitis between 2006 and 2008. RESULTS A total of 523 patients with gallstone pancreatitis were identified, of which 363 (69%) underwent cholecystectomy (72 during the primary admission or within 2 weeks of discharge; 291 following this). Overall, 7% of patients had a complication related to cholecystectomy of which a greater proportion occurred when cholecystectomy was performed within guideline parameters (13% vs 6%; p = 0.07). 11% of patients were readmitted with recurrent pancreatitis prior to surgery, with those undergoing cholecystectomy outside guideline parameters being most at risk (p = 0.006). CONCLUSION This study suggests cholecystectomy within guideline parameters significantly reduces recurrence of pancreatitis but may increase the risk of surgical complications. A prospective randomised study to assess the associated morbidity is required to inform future guidelines.
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Affiliation(s)
- Marianne Johnstone
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom.
| | - Paul Marriott
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - T James Royle
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Caroline E Richardson
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Andrew Torrance
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Elizabeth Hepburn
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Aneel Bhangu
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Abhilasha Patel
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - David C Bartlett
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
| | - Thomas D Pinkney
- West Midlands Research Collaborative, c/o Martha Holmes, Academic Department of Surgery, Room 29, 4th Floor, Queen Elizabeth Hospital, Edgbaston, Birmingham B15 2TH, United Kingdom
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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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Schepers NJ, Besselink MGH, van Santvoort HC, Bakker OJ, Bruno MJ. Early management of acute pancreatitis. Best Pract Res Clin Gastroenterol 2013; 27:727-43. [PMID: 24160930 DOI: 10.1016/j.bpg.2013.08.007] [Citation(s) in RCA: 38] [Impact Index Per Article: 3.5] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Received: 06/27/2013] [Accepted: 08/11/2013] [Indexed: 01/31/2023]
Abstract
Acute pancreatitis is the most common gastro-intestinal indication for acute hospitalization and its incidence continues to rise. In severe pancreatitis, morbidity and mortality remains high and is mainly driven by organ failure and infectious complications. Early management strategies should aim to prevent or treat organ failure and to reduce infectious complications. This review addresses the management of acute pancreatitis in the first hours to days after onset of symptoms, including fluid therapy, nutrition and endoscopic retrograde cholangiography. This review also discusses the recently revised Atlanta classification which provides new uniform terminology, thereby facilitating communication regarding severity and complications of pancreatitis.
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Affiliation(s)
- Nicolien J Schepers
- Department of Operation Rooms, Radboud University Nijmegen Medical Center, Nijmegen, The Netherlands; Department of Gastroenterology and Hepatology, Erasmus Medical Center, Rotterdam, The Netherlands.
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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: 18] [Impact Index Per Article: 1.6] [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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Andersson B, Andrén-Sandberg A, Nilsson J, Andersson R. Survey of the management of acute pancreatitis in surgical departments in Sweden. Scand J Gastroenterol 2012; 47:1064-70. [PMID: 22631566 DOI: 10.3109/00365521.2012.685752] [Citation(s) in RCA: 19] [Impact Index Per Article: 1.6] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 02/07/2023]
Abstract
OBJECTIVE Several international guidelines concerning the treatment of acute pancreatitis has been published during the last decades. However, Scandinavian guidelines are still lacking. The aim of the present study is to identify current treatment strategies for acute pancreatitis in Sweden and to evaluate if there is a need for improvement and the role of guidelines. MATERIAL AND METHODS A questionnaire was e-mailed to the surgical departments at all Swedish hospitals (n = 58) managing patients with acute pancreatitis. Comparisons were made both between university and non-university hospitals, and between hospitals with more versus less than 150,000 persons in the primary catchment population. RESULTS Fifty-one hospitals responded (88%). In median, 65 (12-200) patients with acute pancreatitis are treated yearly at each hospital. Of 51 hospitals, 18 perform a severity classification, with APACHE II being the most commonly used. A majority are of the opinion that a scoring system is not better than the judgment of a senior consultant. In severe acute pancreatitis, 29/48 routinely administer antibiotics, 29/48 use enteral nutrition, and 25/49 have a standardized follow-up plan. The majority considered administration of intravenous fluids as the most important treatment in severe acute pancreatitis. After mild gallstone-induced acute pancreatitis, the corresponding response was cholecystectomy, especially at larger hospitals (p = 0.002). Of 47, 42 are interested in developing a Scandinavian quality register. CONCLUSIONS The results from this first Swedish national survey provide an insight into current traditions of treatment of acute pancreatitis and points, for example, at the lack of early severity stratification. A majority of hospitals are interested in developing a quality register in acute pancreatitis.
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Affiliation(s)
- Bodil Andersson
- Department of Surgery, Clinical Sciences Lund, Skåne University Hospital, Lund, Sweden.
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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: 3.5] [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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46
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Abstract
In the past decade, a significant amount of active and enthusiastic research has changed the way we treat acute pancreatitis (AP) within the first 24 hours of presentation. We highlight the importance of rapid initiation of treatment to help prevent the considerable morbidity and mortality that can occur when interventions are delayed. We review recent data that validate simple and accurate tools for prognostication of AP to replace the older, more tedious methods that relied on numerous factors and required up to 48 hours to complete. Additionally, we aim to provide evidence-based guidelines and end points for fluid resuscitation. Finally, we hope to bring clarification to two previously controversial topics in AP treatment: the use of prophylactic antibiotics and early endoscopic retrograde cholangiopancreatography.
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Affiliation(s)
- Jessica M Fisher
- Section of Gastroenterology and Hepatology, Dartmouth-Hitchcock Medical Center, Lebanon, New Hampshire, USA
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47
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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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48
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Trna J, Vege SS, Pribramska V, Chari ST, Kamath PS, Kendrick ML, Farnell MB. Lack of significant liver enzyme elevation and gallstones and/or sludge on ultrasound on day 1 of acute pancreatitis is associated with recurrence after cholecystectomy: a population-based study. Surgery 2011; 151:199-205. [PMID: 21975288 DOI: 10.1016/j.surg.2011.07.017] [Citation(s) in RCA: 28] [Impact Index Per Article: 2.2] [Reference Citation Analysis] [Abstract] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/16/2010] [Accepted: 07/06/2011] [Indexed: 12/15/2022]
Abstract
BACKGROUND In a population-based study, we examined recurrence rates of acute pancreatitis (AP) after cholecystectomy performed to prevent recurrences of AP. METHODS We abstracted data from medical records of all Olmsted county residents who underwent cholecystectomy at Mayo Clinic for the management of presumed gallstone or idiopathic AP between 1990 and 2005 (n = 239). Based on (i) significantly elevated liver enzymes (≥threefold increase of alanine aminotransferase or aspartate aminotransferase) on day 1 and (ii) the presence of gallstones/sludge in the gall bladder, we categorized patients into 4 groups: A (i + ii), B (i but not ii), C (ii but not i), and D (neither i nor ii). Recurrence rates of AP after cholecystectomy were determined in all groups. RESULTS The median follow-up after cholecystectomy was 99 months (range, 8-220). AP recurred in 13 of 142 patients (9%) in group A, 1 of 17 patients (6%) in group B, 13 of 57 patients (23%) in group C, and 14 of 23 patients (61%) in group D (P < .0001 D vs. all other groups and P = .001 C vs. groups A and B). No difference was seen in recurrence rates in groups A vs. B (P = 1.0). Recurrences were more frequent in patients with normal liver enzymes (A + B vs. C + D; P = .000003) and in patients without sonographic evidence of gallstones/sludge (A + C vs. B + D; P = .0008). CONCLUSION When AP is associated with significantly elevated liver enzymes on day 1, recurrence rates after cholecystectomy are low (9%). However, postcholecystectomy recurrence rates of AP are high in those without such laboratory abnormalities (34%), especially in those without gall bladder stones/sludge (61%) on abdominal ultrasonography. Our results raise doubts about the efficacy of cholecystectomy to prevent recurrent AP in patients with the absence of either a significant elevation of liver tests on day 1 of AP or gallstones and/or sludge in the gall bladder on initial ultrasound examination.
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Affiliation(s)
- Jan Trna
- Department of Internal Medicine and Hepatogastroenterology, University Hospital and Faculty of Medicine, Masaryk University, Brno, Czech Republic
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Anderson K, Brown LA, Daniel P, Connor SJ. Alanine transaminase rather than abdominal ultrasound alone is an important investigation to justify cholecystectomy in patients presenting with acute pancreatitis. HPB (Oxford) 2010; 12:342-7. [PMID: 20590910 PMCID: PMC2951823 DOI: 10.1111/j.1477-2574.2010.00173.x] [Citation(s) in RCA: 11] [Impact Index Per Article: 0.8] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Submit a Manuscript] [Subscribe] [Scholar Register] [Indexed: 12/12/2022]
Abstract
OBJECTIVES The aims of this study were to investigate the predictive value of an elevated level of alanine transaminase (ALT) for biliary acute pancreatitis (AP) and to reconsider the role of abdominal ultrasound (AUS). METHODS All patients admitted to Christchurch Public Hospital with AP between July 2005 and December 2008 were identified from a prospectively collected database. Peak ALT within 48 h of presentation was recorded. Aetiology was determined on the basis of history, AUS and other relevant investigations. RESULTS A total of 543 patients met the inclusion criteria. Patients with biliary AP had significantly higher median (range) ALT than those with non-biliary causes (200 units/l [63-421 units/l] vs. 33 units/l [18-84 units/l]; P < 0.001). An ALT level of >300 units/l had a sensitivity of 36%, specificity of 94%, positive predictive value of 87% and positive likelihood ratio of 5.6 for gallstones. An elevated ALT and negative AUS had a probability of 21-80% for gallstones. CONCLUSIONS An elevated ALT strongly supports a diagnosis of gallstones in AP. Abdominal ultrasound effectively confirms this diagnosis; however, a negative ultrasound in the presence of a raised ALT does not exclude gallstones. In some patients consideration could be given to proceeding to laparoscopic cholecystectomy based on ALT alone.
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Affiliation(s)
- Kerry Anderson
- Department of Surgery, Christchurch Hospital, Christchurch, New Zealand
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50
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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: 1.9] [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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