pancreatite e VLC

1. 1343
Università
di Pisa
U.O. di Chirurgia d’Urgenza
Dipartimento Emergenza Urgenza - Università di Pisa - AOUP
Laparoscopic Cholecystectomy in the management of mild
biliary pancreatitis: our experience
Christian Galatioto, Simone Guadagni, Ismail Cengeli, Rudj Mancini, Giuseppe
Zocco, Massimo Seccia
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2. 1343
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Acute Biliary Pancreatitis
2
 80% of patients with ABP have a mild pancreatitis
 Biliary pancreatitis is caused by temporary obstruction of the
major duodenal papilla by gallstones or sludge
 Acute pancreatitis exhibited positive likelihood ratios of less than
three
 The rate of choledocholithiasis at the time of surgery in mild
acute biliary pancreatitis is still unclear because of spontaneous
passage of small ductal stones
 30–50%: recurrent attack of acute pancreatitis

3. 1343
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Literature
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 Only 35.7% of all patients with ABP underwent cholecystectomy.
 The majority of cholecystectomies (76%) were performed using a laparoscopic
approach.
 The current management of patients with gallstone disease and choledocolithiasis
consists of endoscopic stone extraction followed by laparoscopic cholecystectomy.
 This approach was preferred because local experience in laparoscopic clearance
of common bile duct (CBD) stones was poor in most of the centre participating in the
study.
HPB (Oxford). 2010 Nov;12(9):597-604. doi: 10.1111/j.1477-2574.2010.00201.x. Epub
2010 Sep 2.
Surgical management of acute pancreatitis in Italy: lessons from a prospective
multicentre study.
De Rai P, Zerbi A, Castoldi L, Bassi C, Frulloni L, Uomo G, Gabbrielli A, Pezzilli R,
Cavallini G, Di Carlo V; ProInf-AISP (Progetto Informatizzato Pancreatite Acuta,
Associazione Italiana per lo Studio del Pancreas [Computerized Project on Acute
Pancreatitis, Italian Association for the Study of the Pancreas]) Study Group

4. 1343
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di Pisa
 Conclusion: In uncomplicated mild acute biliary pancreatitis cases, a single-stage
definitive laparoscopic management (VLC + LCBDE), avoiding preoperative ERCP,
can be safely performed during the same admission, after the improvement of
symptoms and local inflammation. Postoperative ERCP should be selectively used in
patients in whom the single-stage method failed to resolve the problem.
 Conclusion: Early laparoscopic cholecystectomy in patients with mild acute biliary
pancreatitis, after symptoms have subsided and laboratory values have normalized,
appears to be a viable and better alternative to interval cholecystectomy. This is
important to prevent a recurrent attacks and to shorten the length of hospital stay.
Literature
4
Am Surg. 2005 Aug;71(8):682-6.
Early versus delayed single-stage laparoscopic eradication for both gallstones and
common bile duct stones in mild acute biliary pancreatitis.
Griniatsos J, Karvounis E, Isla A.
Ann Surg. 2010 Apr;251(4):615-9.
Early cholecystectomy safely decreases hospital stay in patients with mild gallstone
pancreatitis: a randomized prospective study.
Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B, Neville A, Stabile BE, de Virgilio C.

5. 1343
Università
di Pisa
 Laparoscopic cholecystectomy has become the preferred approach for removing
the source of stones in cases acute pancreatitis due to gallstones (Level II, Grade
B).
 There are several approaches for choledocholithiasis (Laparoscopic transcystic
common bile duct exploration, Laparoscopic choledochotomy, ERCP before,
during or after cholecystectomy ) and current data does not suggest clear
superiority of any one approach; decisions regarding treatment are most
appropriately made based on surgeon preference as well as the availability of
equipment and skilled personnel (Level I, Grade A).
 Apart from cases in which an emergency ERCP is indicated, in case of common
bile duct stones, clearance should be obtained by preoperative ERCP or by
laparoscopic removal of bile duct stones during cholecystectomy (GoR A).
Evidence-based guidelines
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SAGES Guidelines 2010

6. 1343
Università
di Pisa
From January 2001 to December 2011
 Retrospective, non-randomized, single-center
 “Laparoscopic first” policy
 Mild biliary acute pancreatitis (Ranson score < 3): 220 cases (M
=97; F =123).
 Mean age:65 years (range 23-94 years).
Study design
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8 9
7
28
24
20
25
29
26
30
32
2001 2002 2003 2004 2005 2006 2007 2008 2009 2010 2011

7. 1343
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di Pisa
Results
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 Mean operative time was 104 min (45-310 min)
 Routine intraoperative cholangiography successfully performed in 219
cases (99,5% of total)
 Conversion to laparotomy was necessary in 3/220 (1,3%). The reasons
for conversion included severe inflammation (n=1) and difficult
dissection secondary to adhesions (n=2)
 The mean time from the admission to surgery was 4,8 days (1-28
days). Post-operative stay was 3,8 days (2-35 days)
 Overall complications occurs in 19 cases (8,6%)
 Only one patient require reintervention
 Mortality rate 1/220 (0,45%)
 Common bile duct stones identified in 51 patients (23,1% of total)

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Complications
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Surgical Complications 7/220 (3,1%)
 Liver bad haematomas: 3 cases that require blood trasfusion.
 Bleeding from the abdominal wall: 2 cases. One patient
underwent angio-embolization to stop bleeding from ruptured
epigastric vessels
 Duodenal leak: 1 case
 Jaundice: 1 case
Medical Complications 12/220 (5,4%)
 Atrial fibrillation: 3 cases
 Myocardial infarction: 1 case
 Pneumonitis: 3 cases
 Pleural effusion: 2 cases
 Pulmonary embolus: 1 cases
 Urinary tract infection: 2 cases

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Total Clearance= 92,1%
40
3 4
LTCE CT ERCP
Choledocholithiasis
1,1%
 Only in 4 cases a complete CBD clearance was not achieved and a drain
was left into the cystic duct and the patient scheduled for post-
operative endoscopic retrograde cholangiopancreatography and
endoscopic sphincterotomy.
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no CBD CBD P value
Total cases 169 51
Male 76 21
Female 93 30
Age (years) 64,5 70,4 NS
OT (min) 91,3 148,8 P<0.05
POS (days) 3,1 4,3 P<0.05
Conversion 2 (1,2%) 1 (2,0%) NS
Mortality 0 (0,0%) 1 (1,9%) P<0.05
OC 14 (8,2%) 5 (9,8%) NS
SC 3 (1,7%) 4 (7,9%) P<0.05
MC 11 (6,5%) 1 (1,9%) NS
Choledocholithiasis
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11. 1343
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di Pisa
 Acceptable morbidity, mortality rates and rate of conversion
 High incidence of Common bile duct stones (CBDS) in mild ABP
 Routine use of intraoperative cholangiography in the presence of
complications of gallstone disease
 Single step laparoscopic treatment of CBDS: high yield of common
bile duct clearance in acute setting
 Longer OT and POS, more specific complications related to surgery
in CBDS group versus no CBDS group
 Surgeon’s expertise in laparoscopy
Conclusions
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