Early versus delayed single-stage laparoscopic eradication for both gallstones and common bile duct stones in mild acute biliary pancreatitis

The optimal timing of laparoscopic cholecystectomy in patients with mild gallstone pancreatitis: A meta-analysis

BACKGROUND

The optimal timing of laparoscopic cholecystectomy (LC) in patients with mild acute gallstone pancreatitis (MAGP) is controversial. The aim of this study was to systematically evaluate and compare the safety and efficacy of early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) in patients with MAGP.

METHODS

A strict search was conducted of the electronic databases, including PubMed, MEDLINE Embase, the ISI Web of Science, and Cochrane Library for all relevant English literature and RevMan5.3 software for statistical analysis was used.

RESULTS

A total of 19 studies comprising 2639 patients were included. There was no significant difference in intraoperative complications [risk ratio (RR) = 1.46; 95% confidence interval (CI) = 0.88-2.41; P = .14)], postoperative complications (RR = 0.81; 95% CI = 0.58-1.14; P = .23), rate of conversion to open cholecystectomy (RR = 1.00; 95% CI = 0.75-1.33; P = .99), operative time (MD = 1.60; 95% CI = -1.36-4.56; P = .29), and rate of readmission (RR = 0.63; 95% CI = 0.19-2.10; P = .45) between the ELC and DLC groups. However, the ELC group was significantly correlated with lower length of hospital stay (MD = -2.01; 95% CI = -3.15 to -0.87; P = .0006), fewer gallstone-related events rates (RR = 0.17; 95% CI = 0.07-0.44; P = .0003), and lower endoscopic retrograde cholangiopancreatography (ERCP) usage (RR = 0.83; 95% CI = 0.71-0.97; P = .02) compared with the DLC group.

CONCLUSION

Early laparoscopic cholecystectomy is safe and effective for patients with MAGP, but the indications and contraindications must be strictly controlled.

Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis

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.

Acute pancreatitis: current perspectives on diagnosis and management

The last two decades have seen the emergence of significant evidence that has altered certain aspects of the management of acute pancreatitis. While most cases of acute pancreatitis are mild, the challenge remains in managing the severe cases and the complications associated with acute pancreatitis. Gallstones are still the most common cause with epidemiological trends indicating a rising incidence. The surgical management of acute gallstone pancreatitis has evolved. In this article, we revisit and review the methods in diagnosing acute pancreatitis. We present the evidence for the supportive management of the condition, and then discuss the management of acute gallstone pancreatitis. Based on the evidence, our local institutional pathways, and clinical experience, we have produced an outline to guide clinicians in the management of acute gallstone pancreatitis.

Timing of Laparoscopic Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review and Meta-Analysis

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.

Controversy and progress for treatment of acute cholangitis after Tokyo Guidelines (TG13)

Tokyo Guideline 2013 (TG13) is an international guideline for the diagnosis, classification and treatment of acute cholangitis. Progress and controversy for the two years after TG13 was summarized. Endoscopic ultrasound (EUS) and magnetic resonance cholangiopancreatography (MRCP) are both effective imaging tests for common bile duct (CBD) stones. More factors e.g. obesity may be involved in severity assessment. Initiation of broad-spectrum antibiotics addressing the typical Gram-negative enteric bacteria spectrum and early biliary drainage are the mainstay therapeutic options. Early laparoscopic exploration is also an option for stone-related nonsevere acute cholangitis besides endoscopic retrograde cholangial or percutaneous transhepatic cholangial drainage. Surgical biliary drainage should be avoided in severe cholangitis.

LABEL procedure: Laser-Assisted Bile duct Exploration by Laparoendoscopy for choledocholithiasis: improving surgical outcomes and reducing technical failure

BACKGROUND

Laparoscopic bile duct exploration (LBDE) is recommended in current treatment guidelines for the management of choledocholithiasis with gallbladder in situ. Failure of this technique is common as a consequence of large or impacted common bile duct (CBD) stones. In this series, we present our experience in using holmium laser lithotripsy as an adjunct to LBDE for the treatment of choledocholithiasis.

METHODS

Between 2014 and 2016, eighteen laparoscopic bile duct explorations utilising holmium laser lithotripsy were performed after failure of standard retrieval techniques.

RESULTS

Choledocholithiasis was successfully treated in 18 patients using laparoscopic holmium laser lithotripsy (transcystically in 14 patients). There was one failure where a CBD stricture prevented the scope reaching the stone. Two medical complications were recorded (Clavien-Dindo I and II). There were no mortalities or re-interventions.

CONCLUSIONS

LABEL technique is a successful and safe method to enhance LBDE in cases of impacted or large stones. In our experience, this approach increases the feasibility of the transcystic stone retrieval and may reduce overall operative time.

Single-stage laparoscopic management of acute gallstone pancreatitis: outcomes at different timings

BACKGROUND

Definitive therapy for gallstone pancreatitis requires eradication of gallstones with cholecystectomy and common bile duct (CBD) clearance. Current guidelines recommend this be done within the same admission and preferably by laparoscopic cholecystectomy and CBD exploration. We report our experience of laparoscopic single-stage management with cholecystectomy and intraoperative cholangiogram followed by laparoscopic bile duct exploration (LBDE) when necessary performed at three different stages.

METHODS

From January 1998 to December 2012, 134 patients (100 females and 34 males) underwent single-stage laparoscopic management of gallstone pancreatitis. Patients were classified according to the timing of surgery: "A", ≤7 days from symptom onset (n=27); "B", 8 to 30 days (n=58) and "C", >30 days (n=49).

RESULTS

LBDE was performed in 30 patients with a success rate of 100%. CBD stones were found in 25 patients (A: 22.2%, B: 22.4%, C: 12.2%). CBD stones were more common in patients undergoing surgery within 30 days of presentation than after this time point (P=0.35). Multiple choledocholithiasis was more frequent in patients treated within 7 days (P=0.04). The 30-day mortality after surgery was 0, with no conversion to an open approach. Overall complication rate was 11.9%, which did not differ significantly between patients treated within 7 days or after this time point (P=0.83).

CONCLUSIONS

This study demonstrated the feasibility and reproducibility of single-stage laparoscopic management of acute gallstone pancreatitis, which has a low complication rate at any stage. Patients undergoing early treatment have a higher incidence of choledocholithiasis and multiple stones than those treated after 30 days, supporting the passage of stones with time.

Update on pathogenesis and clinical management of acute pancreatitis

Acute pancreatitis (AP), defined as the acute nonbacterial inflammatory condition of the pancreas, is derived from the early activation of digestive enzymes found inside the acinar cells, with variable compromise of the gland itself, nearby tissues and other organs. So, it is an event that begins with pancreatic injury, elicits an acute inflammatory response, encompasses a variety of complications and generally resolves over time. Different conditions are known to induce this disorder, although the innermost mechanisms and how they act to develop the disease are still unknown. We summarize some well established aspects. A phase sequence has been proposed: etiology factors generate other conditions inside acinar cells that favor the AP development with some systemic events; genetic factors could be involved as susceptibility and modifying elements. AP is a disease with extremely different clinical expressions. Most patients suffer a mild and limited disease, but about one fifth of cases develop multi organ failure, accompanied by high mortality. This great variability in presentation, clinical course and complications has given rise to the confusion related to AP related terminology. However, consensus meetings have provided uniform definitions, including the severity of the illness. The clinical management is mainly based on the disease´s severity and must be directed to correct the underlying predisposing factors and control the inflammatory process itself. The first step is to determine if it is mild or severe. We review the principal aspects to be considered in this treatment, as reflected in several clinical practice guidelines. For the last 25 years, there has been a global increase in incidence of AP, along with many advances in diagnosis and treatment. However, progress in knowledge of its pathogenesis is scarce.

Timing of cholecystectomy after mild biliary pancreatitis: a systematic review

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.

Cholecystectomy for Acute Gallstone Pancreatitis: Early Vs Delayed Approach

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.

Gallstone-induced acute pancreatitis

In the care of acute pancreatitis, a prompt search for the etiologic condition of the disease should be conducted. A differentiation of gallstone-induced acute pancreatitis should be given top priority in its etiologic diagnosis because it is related to the decision of treatment policy. Examinations necessary for diagnosing gallstone-induced acute pancreatitis include blood tests and ultrasonography. Early ERCP/ES should be performed in patients with gallstone-induced acute pancreatitis if a complication of cholangitis and a prolonged passage disorder of the biliary tract are suspected. The treatment for bile duct stones with the use of ERCP/ES alone is not recommended in cases of gallstone-induced pancreatitis with gallbladder stones. Cholecystectomy for gallstone-induced acute pancreatitis should be performed using a laparoscopic procedure as the first option as soon as the disease has subsided.

Cholecystectomy and sphincterotomy in patients with mild acute biliary pancreatitis in Sweden 1988 - 2003: a nationwide register study

Background

Gallstones represent the most common cause of acute pancreatitis in Sweden. Epidemiological data concerning timing of cholecystectomy and sphincterotomy in patients with first attack of mild acute biliary pancreatitis (MABP) are scarce. Our aim was to analyse readmissions for biliary disease, cholecystectomy within one year, and mortality within 90 days of index admission for MABP.

Methods

Hospital discharge and death certificate data were linked for patients with first attack acute pancreatitis in Sweden 1988-2003. Mortality was calculated as case fatality rate (CFR) and standardized mortality ratio (SMR). MABP was defined as acute pancreatitis of biliary aetiology without mortality during an index stay of 10 days or shorter. Patients were analysed according to four different treatment policies: Cholecystectomy during index stay (group 1), no cholecystectomy during index stay but within 30 days of index admission (group 2), sphincterotomy but not cholecystectomy within 30 days of index admission (group 3), and neither cholecystectomy nor sphincterotomy within 30 days of index admission (group 4).

Results

Of 11636 patients with acute biliary pancreatitis, 8631 patients (74%) met the criteria for MABP. After exclusion of those with cholecystectomy or sphincterotomy during the year before index admission (N = 212), 8419 patients with MABP remained for analysis. Patients in group 1 and 2 were significantly younger than patients in group 3 and 4. Length of index stay differed significantly between the groups, from 4 (3-6) days, (representing median, 25 and 75 percentiles) in group 2 to 7 (5-8) days in groups 1. In group 1, 4.9% of patients were readmitted at least once for biliary disease within one year after index admission, compared to 100% in group 2, 62.5% in group 3, and 76.3% in group 4. One year after index admission, 30.8% of patients in group 3 and 47.7% of patients in group 4 had undergone cholecystectomy. SMR did not differ between the four groups.

Conclusion

Cholecystectomy during index stay slightly prolongs this stay, but drastically reduces readmissions for biliary indications.

Management of preoperatively suspected choledocholithiasis: a decision analysis

BACKGROUND

The management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5-15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients.

METHODS

A decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality.

RESULTS

One-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality.

CONCLUSION

LCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.

Endoscopic sphincterotomy and interval cholecystectomy are reasonable alternatives to index cholecystectomy in severe acute gallstone pancreatitis (GSP)

BACKGROUND

UK guidelines for gallstone pancreatitis (GSP) advocate definitive treatment during the index admission, or within 2 weeks of discharge. However, this target may not always be achievable. This study reviewed current management of GSP in a university hospital and evaluated the risk associated with interval cholecystectomy.

METHODS

All patients that presented with GSP over a 4-year period (2002-2005) were stratified for disease severity (APACHE II). Patient demographics, time to definitive therapy [index cholecystectomy; endoscopic sphincterotomy (ES); Interval cholecystectomy], and readmission rates were analysed retrospectively.

RESULTS

100 patients admitted with GSP. Disease severity was mild in 54 patients and severe in 46 patients. Twenty-two patients unsuitable for surgery underwent ES as definitive treatment with no readmissions. Seventy-eight patients underwent cholecystectomy, of which 40 (58%) had an index cholecystectomy, and 38 (42%) an interval cholecystectomy. Only 10 patients with severe GSP had an index cholecystectomy, whilst 30 were readmitted for Interval cholecystectomy (p = 0.04). The median APACHE score was 4 [standard deviation (SD) 3.8] for index cholecystectomy and 8 (SD 2.6) for Interval cholecystectomy (p < 0.05). Median time (range) to surgery was 7.5 (2-30) days for index cholecystectomy and 63 (13-210) days for Interval cholecystectomy. Fifty percent (19/38) of patients with GSP had ES prior to discharge for interval cholecystectomy. Two (5%) patients were readmitted: with acute cholecystitis (n = 1) and acute pancreatitis (n = 1) , whilst awaiting interval cholecystectomy. No mortality was noted in the Index or Interval group.

CONCLUSIONS

This study demonstrates that overall 62% (22 endoscopic sphincterotomy and 40 index cholecystectomy) of patients with GSP have definitive therapy during the Index admission. However, surgery was deferred in the majority (n = 30) of patients with severe GSP, and 19/30 underwent ES prior to discharge. ES and interval cholecystectomy in severe GSP is associated with minimal morbidity and readmission rates, and is considered a reasonable alternative to an index cholecystectomy in patients with severe GSP.