The optimal timing of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis is not standardized. Our objective was to determine if patients with mild gallstone pancreatitis (three or fewer Ranson's criteria) can safely proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving. We reviewed the charts of all adults admitted to our institution with gallstone pancreatitis from January 1999 until June 2002 who had LC performed by either surgeon 1 (group 1) or surgeon 2 (group 2). Surgeon 1 preferred to delay surgery until normalization of amylase and complete resolution of abdominal tenderness, whereas surgeon 2 preferred to proceed to LC as soon as serum amylase was decreasing and abdominal tenderness was improving. The two groups were well matched for sex, age, Ranson's criteria, and percentage requiring endoscopic retrograde cholangiopancreatography. Average total hospital stay was 4.7 days in group 1 versus 3.5 days in group 2 (P = 0.01). There was no statistical difference in complication rate between the two groups (10% in group 1 vs 11% in group 2, P = 0.12). The data suggest that hospital stay can be shortened with no increased complication rate if patients with mild biliary pancreatitis proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving.
"Our finding that the majority of Swedish patients with first attack of MABP underwent gallbladder surgery after the index stay (necessitating a new admission and additional convalescence) concurs with experience from the United Kingdom , where delay of cholecystectomy was found to be associated with a high readmission rate . According to a questionnaire study, only 58% of consultants preferred early cholecystectomy (at index stay or within 4 weeks of index admission) for MABP  although it is safe to proceed to cholecystectomy as soon as the serum amylase-level has started to decline [15,16]. Similar deviations from the UK guidelines  have been reported from Spain , Germany , Italy  and the US . "
[Show abstract][Hide abstract] ABSTRACT: 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.
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).
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.
Cholecystectomy during index stay slightly prolongs this stay, but drastically reduces readmissions for biliary indications.
"Patients with CBD stones confirmed by imaging underwent ERCP at the earliest and then LC at the next available opportunity during regular hours.10 Those with pancreatitis without CBD stones were observed for clinical and biochemical recovery before having LC.11 "
[Show abstract][Hide abstract] ABSTRACT: The prevalence of gallstone disease in the community makes it an important area of service in district general hospitals. Laparoscopic surgical techniques in synergy with modern imaging and endoscopic and interventional techniques have revolutionized the treatment of gallstone disease, making it possible to provide prompt and definitive care to patients.
Patients with gallstone disease were treated based on a predetermined protocol by a special-interest team depending on the patient's mode of presentation. Data were collected and analyzed prospectively.
Our team treated 1332 patients with gallstone disease between September 1999 and December 2007. Patients (249) with acute symptoms presented through Accident and Emergency (A&E). Despite varied presentations, laparoscopic treatment was possible in all but 8 patients. The study comprised 696 patients who underwent laparoscopic cholecystectomy (LC) as in-hospital (23 hour) cases in a stand-alone center, and 257 outpatients and 379 inpatients. Sixty-seven patients with acute cholecystitis had their surgery within 96 hours of acute presentation. Seventy patients had laparoscopic subtotal cholecystectomy. The overall morbidity was 2.33% with 3 patients having residual common bile duct stones; 3 patients had biliary leak from cystic or accessory duct stumps and one had idiopathic right segmental liver atrophy; 19 had wound infections, 5 had port-site hernia. No mortalities occurred during the 30-day follow-up.
We believe that prompt investigation with imaging and endoscopic intervention if needed along with LC at the earliest safe opportunity by a specialized dedicated team represents an effective method for treating gallstone disease in district general hospitals. Our experience with over 1000 patients has offered us the courage of conviction to say that justice is finally here for gallstone sufferers.
JSLS: Journal of the Society of Laparoendoscopic Surgeons / Society of Laparoendoscopic Surgeons 03/2008; 12(4):389-94. · 0.91 Impact Factor
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