Appraisal of the surgical management of acute gallstone pancreatitis

ABSTRACT

The usefulness of corrective biliary surgery in gallstone pancreatitis is well established. Three questions are still controversial What is the ideal timing of surgery? what is the optimal plan of treatment in severe cases? what is the role of endoscopic sphincterotomy [ES]? In this prospective study, surgical intervention in various stages of gallstone pancreatitis was evaluated with special reference about the value of ES. Fifty-two patients were included in this study on the basis of consistent clinical picture, hyperamylasemia and an ultrasound evidence of biliary stones. Forty patients [77%] had mild pancreatitis. while 12 patients [23%] had severe pancreatitis. Patients were operated upon within 48 hours of admission [Group I; 17 patients], within 6-8 days after the attack subsided [gropu II; 15 patients], or after 1-3 monts latter to preliminary conservative treatment [Group III; 20 patients]. In group I, II, operation was relatively easy and could be accomplished with minimal morbidity. All patients with oedematous pancreatitis had a prompt recovery with no recorded complications. In cases of haemorrhagic pancreatitis, although the opration and postoperative course were more difficult, 5 out of 7 patients recovered from their illness denoting that early surgery coud be beneficial. two patients with necrotizing pancreatitis died due to fulminent sepsis and multisystem failure, while another patient died with myocardial infarction 2 weeks postoperatively irrespective of recovery from original illness. Group III patients were treated conservatively, discharged and then readmitted for elective surgery with no recorded deaths nor significant complications. In all patients, cholecystectomy and operative cholangiography were performed with common bile duct [CBD] exploraiton when indicated. ES was used in 4 cases; retained stone [one patient], prior to laparoscopic cholecystectomy [one patient] and cholangitis [2 patients]. Drainage procedures were carried out in 3 cases; tranduodenal sphincterotomy [one patient] and choledochoduodenostomy [2 patients]. Mortality rates were 0% and 25% in mild and severe cases respectively with an overall mortality rate of 5.8%. Hospitalization was significantly shorter in the groups operated on during the primary admission. In conclusion, we recommend early surgery in all mild cases whereas in severe cases, the tinting of sugery should be relient on clinical findings. A more conservative approach in haemorrhagic- necrotizing pancreatitis is required. ES could be used safely to clear CBD in cases of retained stones, cholangitis or prior to laparoscopic cholecystectomy