Biliary Pancreatitis

3/24/2003

Question: What is the pathophysiology and treatment for biliary pancreatitis?

<2>

Unique Identifier:10492153

Authors: Aiyer MK. Burdick JS. Sonnenberg A.

Institution: Department of Medicine, University of Illinois, Peoria, USA.

Title: Outcome of surgical and endoscopic management of biliary pancreatitis.

Source: Digestive Diseases & Sciences. 44(8):1684-90, 1999 Aug.

Abstract: The aims of the study were to compare the outcomes of biliary pancreatitis after endoscopic and surgical treatment and define the demographic and clinical characteristics that affect the outcomes. All inpatients with biliary pancreatitis followed at hospitals of the Department of Veterans Affairs during 1988-1994 were included in a case-control study. Of 2075 patients with biliary pancreatitis, 650 were first treated by biliary endoscopy and 1425 by cholecystectomy. Compared with cholecystectomy, biliary endoscopy was associated with older age, admission to nonsurgical service, more complicated pancreatitis, and choledocholithiasis. Seventy-one patients died. Death occurred more often in older patients with multiple comorbid conditions and complications of biliary pancreatitis. Overall length of hospital stay was positively correlated with complications, choledocholithiasis, comorbidity, and deferment of endoscopic or surgical procedure. After adjusting for other confounding variables, both types of treatment resulted in similar death rates and lengths of hospitalization. In conclusion, compared with cholecystectomy, biliary endoscopy is chosen preferentially in older patients with choledocholithiasis or a complication of their pancreatitis. Despite such selection bias, biliary endoscopy results in similar outcomes as surgery. Early intervention by either strategy reduces the length of hospital stay.

 Link Directly to Fulltext Article at Publisher

<4>

Unique Identifier:9790209

Authors: Schwesinger WH. Page CP. Gross GW. Miller JE. Strodel WE. Sirinek KR.

Institution: Department of Surgery, University of Texas Health Science Center at San Antonio, USA.

Title: Biliary pancreatitis: the era of laparoscopic cholecystectomy.

Source: Archives of Surgery. 133(10):1103-6, 1998 Oct.

Abstract: OBJECTIVE: To evaluate the efficacy and safety of a combined approach to the treatment of biliary pancreatitis using laparoscopic cholecystectomy and selective endoscopic retrograde cholangiopancreatography (ERCP). DESIGN: Consecutive case series. SETTING: Tertiary care center. PATIENTS: All patients undergoing primary operations for biliary pancreatitis during 2 time periods were included. In the open era (June 1982 through May 1988), there were 276 patients; in the laparoscopic era (January 1996 through June 1997), there were 114 patients. INTERVENTIONS: Open cholecystectomy with or without common bile duct exploration (CBDE); laparoscopic cholecystectomy with selective ERCP and/or laparoscopic CBDE. MAIN OUTCOME MEASURES: Two periods were compared for morbidity, mortality, the duration of preoperative and postoperative stays, and the total length of hospitalization. RESULTS: Both groups were demographically similar and had the same mortality (1.9%). Laparoscopic cholecystectomies provided a preoperative stay comparable to open cholecystectomy (6.4 vs 5.8 days), a shorter postoperative stay (1.5 vs 8.5 days), a lower incidence of CBDE (6.6% vs 26%), and a lower morbidity (8% vs 13.7%). The addition of an ERCP to laparoscopic cholecystectomy was associated with prolongation of the preoperative stay (7.4 vs 5.0 days), a comparable postoperative stay, a lower conversion rate (7.5% vs 13%), and fewer CBDEs (3% vs 13%). In 27 (42%) of the 64 ERCP cases, no stones were found. CONCLUSIONS: Treatment of biliary pancreatitis with combined laparoscopic cholecystectomy and selective ERCP is safe and effective and is associated with a shorter hospitalization and fewer CBDEs than open cholecystectomy. Unnecessary ERCPs can be reduced by improved selection criteria or greater dependence on operative CBDE.

 Link Directly to Fulltext article in Ovid

<7>

Unique Identifier:8995085

Authors: Folsch UR. Nitsche R. Ludtke R. Hilgers RA. Creutzfeldt W.

Institution: Department of Medicine, University of Kiel, Germany.

Title: Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. The German Study Group on Acute Biliary Pancreatitis.[comment].

Source: New England Journal of Medicine. 336(4):237-42, 1997 Jan 23.

Abstract: BACKGROUND: The role of early endoscopic retrograde cholangiopancreatography (ERCP) and papillotomy in the treatment of patients who have acute biliary pancreatitis without obstructive jaundice is uncertain. METHODS: We conducted a prospective, multicenter study in which 126 patients were randomly assigned to early ERCP (within 72 hours after the onset of symptoms) and endoscopic papillotomy for the removal of stones in the common bile duct, when appropriate, and 112 patients were assigned to conservative treatment. In the conservative-treatment group, ERCP was performed within three weeks if signs of biliary obstruction or sepsis developed. Overall mortality, mortality due to pancreatitis, and complications were compared in the two groups. RESULTS: Early ERCP was successful in 121 of the 126 patients in the invasive-treatment group. Endoscopic papillotomy was performed to remove bile-duct stones in 58 patients; stones were successfully extracted in 57. ERCP was performed in 22 of the 112 patients in the conservative-treatment group; papillotomy for stone removal was successful in 13 patients. Fourteen patients in the invasive-treatment group and 7 in the conservative-treatment group died within three months (P=0.10); 10 patients in the invasive-treatment group and 4 in the conservative-treatment group died from acute biliary pancreatis (P=0.16). The overall rate of complications was similar in the two groups, but patients in the invasive-treatment group had more severe complications. Respiratory failure was more frequent in the invasive-treatment group, and jaundice was more frequent in the conservative-treatment group. CONCLUSIONS: In patients with acute biliary pancreatis but without obstructive jaundice, early ERCP and sphincterotomy were not beneficial.

Link Directly to Fulltext article in Ovid

<9>

Unique Identifier:8712905

Authors: McGrath MF. McGrath JC. Gabbay J. Phillips EH. Hiatt JR.

Institution: Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, USA.

Title: Safe laparoendoscopic approach to biliary pancreatitis in older patients. [Review] [21 refs]

Source: Archives of Surgery. 131(8):826-31; discussion 831-3, 1996 Aug.

Abstract: OBJECTIVE: To evaluate management strategies for biliary pancreatitis in different age groups. DESIGN: Retrospective review. SETTING: Large private metropolitan teaching hospital. PATIENTS: Patients seen between January 1991 and December 1994 with a diagnosis of biliary pancreatitis (N = 136) divided into 2 groups (group 1, aged < 65 years; group 2, aged > or = 65 years). INTERVENTIONS: Primary treatments included endoscopic retrograde cholangiography (n = 36) alone or with endoscopic sphincterotomy (n = 27); operative procedures, including cholecystectomy by laparoscopic (n = 54) or open (n = 16) approaches; or no definitive therapy (n = 22). Secondary treatments of common bile duct stones included laparoscopic transcystic bile duct exploration (n = 5), open common bile duct exploration (n = 4), or postoperative endoscopic retrograde cholangiography (n = 10). MAIN OUTCOME MEASURES: Success of interventions, incidence and treatment of common bile duct stones, morbidity and mortality rates, frequency of retained stones, and length of hospitalization. RESULTS: Numbers of Ranson criteria were higher for older patients (group 1, 0.83 +/- 0.12 vs group 2, 1.57 +/- 0.11 [mean +/- SEM]; P < .001). Primary endoscopic retrograde cholangiography with or without endoscopic sphincterotomy was performed earlier than operative procedures, with a significantly higher incidence of common bile duct stones (72% vs 19%; P < .001). Number of primary procedures and complication and mortality rates for endoscopic retrograde cholangiography with or without endoscopic sphincterotomy were 36, 8%, and 3%, respectively; for laparoscopic cholecystectomy, 54, 9%, and 2%, respectively; and for open cholecystectomy, 16, 6%, and 19%, respectively. For complication and mortality rates, there were no statistical differences between groups or among treatments. Deferred therapy was used in 30 patients, with 20% readmitted for recurrence of biliary pancreatitis. Length of intensive care unit and total hospital stay were similar for all groups and treatments. CONCLUSIONS: Older patients with biliary pancreatitis may be safely treated with a combined laparoendoscopic approach. Management of common bile duct stones depends on age, with laparoscopic transcystic duct exploration or open common bile duct exploration preferred for younger patients and laparoscopic transcystic duct exploration or postoperative endoscopic sphincterotomy for older ones. Deferred therapy has a substantial relapse rate. [References: 21]

 Link Directly to Fulltext article in Ovid

<10>

Unique Identifier:7615262

Authors: Banerjee AK. Steele RJ.

Institution: Department of Surgery, Northern General Hospital, Sheffield.

Title: Current views on the pathophysiology of acute biliary pancreatitis.

Source: Gut. 36(6):803-5, 1995 Jun.

<11>

Unique Identifier:7726030

Authors: Steer ML.

Institution: Department of Surgery, Beth Israel Hospital, Boston, MA 02215, USA.

Title: Recent insights into the etiology and pathogenesis of acute biliary pancreatitis. [Review] [28 refs]

Source: AJR. American Journal of Roentgenology. 164(4):811-4, 1995 Apr.