Gallstone pancreatitis in the era of laparoscopic cholecystectomy

Abstract

This study focused on the management of all patients admitted with a diagnosis of gallstone pancreatitis (GP) since the advent of laparoscopic cholecystectomy in our institution. The inpatient and outpatient medical records of all 172 patients with GP admitted from November 1990 to June 1995 were retrospectively reviewed. The main outcome measures were the effectiveness of and complications associated with surgical and endoscopic treatment of GP, including the incidence and management of common bile duct stones. One hundred fifty-four patients underwent cholecystectomy (89 laparoscopic and 65 open), usually within 3 to 5 days after admission when the amylase had returned to normal or nearly normal. There was a progressive increase in the use of laparoscopy, with 6 per cent of cholecystectomies in 1991 performed laparoscopically and 88 per cent in the first half of 1995. Overall conversion rate was 16 per cent. A total of 33 patients (19.2%) underwent endoscopic retrograde cholangiopancreatography (ERCP): 9 preoperatively and 12 postoperatively, and in 12 patients it served as definitive treatment due to advanced age and/or serious associated medical problems. Of the 24 positive intraoperative cholangiograms, 14 had common bile duct (CBD) stones. CBD stones were found in a total of only 32 patients (18.6%). Laparoscopic CBD exploration was not performed during this time period. There were 16 (8.6%) complications and two deaths (1.2%). Six patients refused all treatment. There were no unsuccessful postoperative ERCPs, and no patient underwent reoperation. In conclusion, our approach to patients with GP is safe and effective, with a low rate of complications. Considering the relatively low incidence of CBD stones in GP (18.6% in this series), routine preoperative ERCP is not indicated, because it has some risk and the vast majority of studies would be negative. In certain highly selected patients with multiple medical problems and/or advanced age, endoscopic sphincterotomy may be considered the definitive treatment. The optimal management of GP and CBD stones, however, depends on the skills and resources available as well as patient preference.