Early versus Delayed Single-Stage Laparoscopic ...

Early versus Delayed Single-Stage Laparoscopic Eradication for Both Gallstones and Common Bile Duct Stones in Mild Acute Biliary Pancreatitis JOHN GRINIATSOS, M.D., EVANGELOS KARVOUNIS, M.D., ALBERTO ISLA, M.D., F.R.C.S.

From the Upper GI and Laparoscopic Unit, Baling Hospital, Southall-Middlesex, London, United Kingdom

Several studies addressed that preoperative endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) clearance, followed by interval laparoscopic cholecystectomy (two-stage approach), constitutes the most common practice in cases of uncomplicated mild acute biliary pancreatitis. Between June 1998 and December 2002, 44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were treated in our unit. All patients were electively submitted to surgery after subsidence of the acute symptoms, and for definitive treatment we favored the single-stage laparoscopic management, avoiding preoperative ERCP. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. Twenty patients were operated upon within 2 weeks since the attack of the acute symptoms and constitute the early group (n = 20), whereas 24 patients underwent an operation later on and constitute the delay group (n = 24). We retrospectively compare the safety, effectiveness, and outcome after the single-stage laparoscopic management between the two groups of patients. Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients, while an additional LCBDE was performed in the remaining 6 patients (14%), and all operations were achieved laparoscopically. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay. During the follow-up, none of the patients experienced recurrent pancreatitis. In uncomplicated mild acute biliary pancreatitis cases, a single-stage definitive laparoscopic management, 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 singlestage method failed to resolve the problem.

HE SURGICAL MANAGEMENT in mild acute biliary pancreatitis cases consists of diagnosis and clearance of common bile duct (CBD) stones as well as definitive gallstones eradication by cholecystectomy.' Although acute pancreatitis, as a form of symptomatic cholelithiasis, constitutes an absolute indication for cholecystectomy^ and laparoscopic cholecystectomy constitutes the treatment of choice,^ the timing for gallstones eradication after acute symptoms subsidence and the best approach to diagnose and treat concomitant choledocholithiasis remain controversial, In the current study, we retrospectively compare the

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Address correspondence and reprint requests to John Griniatsos, M.D., 43 Tenedou Street, G.R. 113-61, Athens, Greece.

safety, effectiveness, and outcome after single-stage laparoscopic management for both gallstones and common bile duct stones eradication in two groups of patients who underwent early and delayed definitive treatment for uncomplicated mild acute biliary pancreatitis. Patients and Methods I" the current study, the diagnosis of acute biliary pancreatitis was established in the presence of generalized or upper abdominal pain and tenderness, elevation of serum amylase level more than three times the normal, documented gallstones, and absence of other factors known to cause pancreatitis. The severity of pancreatitis was estimated using the Modified Imrie

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(Glasgow) Scoring System,"* which includes the following positive criteria: PaOj 55 years, white blood cell count >15 x 10^/L, calcium 16 mmol/L, lactate dehydrogenase (LDH) >600 U/L, albumin 10 mmol/L. Zero to two positive criteria, based on initial admission score and subsequent repeat tests over 48 hours, constitute mild disease. During the acute phase of the disease, all patients were admitted as an emergency and were managed conservatively. On admission, all of them had undergone an abdominal ultrasound (US), which was diagnostic for gallstones in all cases, suggesting the biliary origin of the pancreatitis. In contrast, US was suggestive for CBD stone presence in two patients, whereas in the remaining 42 patients it was unable to detect any CBD stone(s). Since June 1998, we favored the single-stage definitive laparoscopic management, avoiding preoperative endoscopic retrograde cholangiopancreatography (ERCP), in patients with mild acute biliary pancreatitis, and all patients were prospectively enrolled. Patients were operated electively, when symptoms had been settled and laboratory results had been improved. All patients underwent laparoscopic cholecystectomy plus fluoroscopic intraoperative cholangiogram (IOC). If filling defect(s) were detected in the IOC, a finding suggestive of concomitant choledocholithiasis, laparoscopic common bile duct exploration (LCBDE) was added in the same sitting. We excluded from the study patients a) with three or more Imrie positive criteria (severe pancreatitis), b) who developed obstructive jaundice or cholangitis during the acute phase of the disease treated by urgent ERCP and sphincterotomy,^ c) who developed pancreatic pseudocyst or pancreatic necrosis, treated accordingly,^ d) who were not candidates for definitive surgical treatment, and e) who were referred to our unit for laparoscopic cholecystectomy after an episode of uncomplicated mild acute biliary pancreatitis having undergone a preoperative ERCP. Statistical differences between the groups were determined by the Student's /-test. Statistical significance was defined at P < 0.05. All statistical calculations were performed using the STATA statistical package (StataQuest Version 4.0, College Station, TX). Results

Between June 1998 and December 2002,44 patients (35 females and 9 males with a median age of 62 years) suffering from uncomplicated mild acute biliary pancreatitis were surgically treated in our unit. Twenty patients were operated on within 2 weeks since the attack of the acute symptoms and constitute

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the early group (n = 20), whereas 24 patients were operated later on and constitute the delayed group (n = 24). The delay in the second group was related to delay in improvement of acute pancreatitis symptoms for more than 2 weeks since the acute attack (n = 4), severe cardiac and respiratory comorbidity requiring optimization prior to surgery (n = 4), and delay in coordination between the clinicians (n = 4). Twelve (n = 12) additional patients who had been conservatively treated during the acute phase of the disease in other units, discharged after the subsidence of acute symptoms and readmitted later on, were referred to our unit for laparoscopic cholecystectomy. Seven out of the 24 patients (29%) in the delayed group experienced ongoing symptoms while waiting for the operation. One patient experienced a second episode of acute pancreatitis, and she was operated on 9 days after the new attack and after the subsidence of the acute symptoms. Obviously, this patient was enrolled in the delayed group of the current study. Six additional patients complained for symptoms related to gallstones presence such as dyspepsia or postmeal right upper quadrant "discomfort" or multiple episodes of self-limited colicky right upper quadrant pain. In the early group, the median elapse period between the onset of symptoms and the time of operation was 2 weeks interquartile range (I.R. 1-2), whereas in the delayed group the median elapse period was 8.5 weeks (I.R. 6.75-13). Laparoscopic cholecystectomy alone constituted the definitive treatment in 38 patients. Three patients in the early and three additional patients in the delayed group were found to have coexisting choledocholithiasis, and a LCBDE was performed in the same sitting with laparoscopic cholecystectomy. In five of the patients who had undergone LCBDE, IOC revealed one or more filling defects into a dilated CBD, and these patients were explored through a longitudinal choledochotomy. In the sixth patient, IOC revealed linear defect and not formal stone into a normal size CBD, and this patient was explored through a transcystic approach. In the choledochotomy group of patients (n = 5) at the end of the procedure, biliary decompression was achieved by T-tube placement in 4 cases, and laparoscopic placement of a biliary endoprosthesis and primary closure of the CBD was chosen in one patient. All operations were achieved laparoscopically. Compared to fluoroscopic IOC findings, the results of the preoperative abdominal US scan for CBD stone detection were classified as True-i- (n = 1), True(n = 37), Ealse-H (n = 1) and Ealse- (n = 5). Some of the preoperative laboratory values and the CBD size (as calculated by the IOC) in the groups of patients with (n = 6) and without (n = 38) concomi-

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1. Preoperative Laboratory Values and Intraoperative Findings in the Groups of Patients With and Without Concomitant CBD Stones

TABLE

Gallstones and CBD Gallstones Group Stones Group Parameter (n = 38) (n = 6) p Value 12.9(12.5-13.3) 0.52 13.1(12.5-13.5) Median + LR. Hemoglobin (g/dL) Median + l.R. 6,550 (5,400-7,775) 8,050(7,125-9,650) 0.40 WBC (X lO^/L) Median + l.R. 8 (7-12) 7 (5.5-9) 0.04 Bilirubin (mmol/L) Alk. Phos. (U/L) Median + l.R. 221.5(161-331) 277.5 (169-508) 0.12 AST (U/L) Median + l.R. 30.5 (21^6) 67 (31-77) 0.15 ^GT (U/L) Median + l.R. 77.5(32-165.5) 72 (32-263) 0.27 LDH (U/L) Median + l.R. 385 (213-525) 487(247-652) 0.19 CRP (mg/L) Median + l.R. 4 (4-14) 34.5 (19-50) 0.20 CBD diameter in IOC (mm) Median + l.R. 4 (4-6) 5.5 (4-8.5) 0.09 WBC, white blood cell count; AST, aspartate aminotranslerase; 7GT, gamma-glutamyl translerase; LDH, lactate dehydrogenase; l.R., interquartile range; CBD, common bile duct; IOC, intraoperative cholangiogram

safely performed 5-6 days after the onset of acute symptoms, although no attention was paid to the severity of the disease.^ In 1998, national guidelines from the British Society of Gastroenterology (BSG) recommended, more clearly, that in uncomplicated mild acute biliary pancreatitis cases, laparoscopic cholecystectomy should ideally be performed within 2 weeks and no longer than 4 weeks after the onset of acute symptoms.^ Since then, however, several publications'-^~'° addressed that the guidelines for the management of acute biliary pancreatitis are not being met, and a recent survey of the timing for operation'' concluded that the management of cholelithiasis in patients with mild acute biliary pancreatitis in the United Kingdom remains suboptimal. Failure to meet the timing criterion was mainly related to delay in the clinical improvement of the patient,'° delay in seeking the care of a specialist,^" the preference of the surgeon in the two-stage approach,'^ the time-consuming coordination between the clinicians,^ and the long waiting lists.^ In the current study, similar etiologies caused delay in the definitive management. Although there is a worldwide agreement favoring early laparoscopic cholesystectomy in mild acute biliary pancreatitis cases, controversies still exist for the Discussion best method to diagnose and treat possible concomiIn 1993, the NIH recommended that laparoscopic tant choledocholithiasis, as there is no accurate cholecystectomy in cases of acute pancreatitis can be method for its preoperative prediction so far.'^

tant CBD stones are presented in Table 1. Although not statistically significant (probably reflecting the retrospective nature of the study and the small number of patients), a trend for abnormal liver function tests (LFTs) and larger CBD size in the CBD stones group of patients is documented. Postoperatively, one patient in the early group who had undergone an uneventful laparoscopic cholecystectomy developed a soft tissue hematoma at the site of the right subcostal trocar. The hematoma was successfully treated by percutaneous drainage under ultrasound guidance, and the patient was discharged on 13th postoperative day. In the delayed group, one patient who had undergone laparoscopic cholecystectomy and LCBDE followed by T-tube placement for biliary decompression experienced T-tube dislodgement treated by laparoscopic reoperation and T-tube re-placement on the 2nd postoperative day and was discharged on the 22nd postoperative day. There was no statistically significant difference between the groups in terms of operative time, incidence of concomitant choledocholithiasis, morbidity rate, and postoperative hospital stay (Table 2). During the follow-up (median 34 months, l.R. 24-42), none of the patients experienced recurrent pancreatitis.

TABLE 2. Intraoperative and Postoperative Details Parameter Operative time (min) (Median + LR.) Number of patients with coexisting CBD stones Number of extracted CBD stones (Median + l.R.) Postoperative complications Postoperative hospital stay (days) (Median + LR.) Recurrent postoperative pancreatitis CBD, common bile duct

Early Group (n = 20)

Delayed Group (n = 24)

75(60-105)

75(55-115)

3

4 (3-5) 1

2(2-3) 0

3

2(1-7) 1

2 (1-2.25) 0

p Value 0.51 0.81 0.76 0.90 0.94

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Population-based study"* and reports from several institutions^''2.15 addressed that preoperative ERCP for CBD clearance followed by interval laparoseopic cholecystectomy (two-stage approach) constitutes the most common practice for definitive treatment in mild acute biliary pancreatitis cases. However, it is wellknown that during the course of an uncomplicated acute pancreatitis, the prevalence of CBD calculi decreases from 74 per cent in ERCP that were performed within 14 hours,^ to 48 per cent in ERCP that were performed within 24 hours^ and to 5 per cent to 10 per cent'^'"' in patients who were operated upon or underwent ERCP within a week after admission. These results indicate that if period of time is allowed, there is spontaneous gallstone passage. The current study concluded in 14 per cent overall coexistence of CBD stones but did not conclude in statistically significant differences in the incidence of choledocholithiasis between the patients who underwent early or delayed surgical treatment. On the other hand, a meta-analysis'"^ concluding that a history of pancreatitis constitutes a poor indicator for the presence of common bile duct stones; a prospective randomized trial^ addressing that ERCP and papillotomy are not beneficial in cases without obstructive jaundice or cholangitis; a recent study'^ addressing that patients with benign acute biliary pancreatitis do not need an endoscopic approach; our previous report'^ that a single-stage procedure is feasible and safe; and BSG recommendations^ favoring laparoseopic CBD clearance in the same sitting with laparoseopic cholecystectomy if the local experience is available, put severe doubts on the two-stage approach for the treatment of mild acute biliary pancreatitis. Throughout the current study, we favored the single-stage management in mild acute biliary pancreatitis cases, avoiding preoperative ERCP, and fluoroscopic IOC was chosen as the imaging method for extrahepatic biliary tree visualization. IOC has been proposed as safe^° and accurate, with sensitivity and specificity between 95 per cent and 100 per cent in selected or unselected cases.^*"^^ xhe main advantage of the method is its very low incidence of false negative results,^^' ^3 but its main disadvantage is that interpretation of a positive result is subjective to the surgeon.23 If IOC revealed filling defects, LCBDE can be performed either transcystically or through a choledochotomy according to specific indications.2'*' 2^ Because small gallstones cause acute pancreatitis, the current study, in agreement with other studies,'^' 26 did not face any case of impacted stone, and laparoseopic stone extraction was successful in 100 per cent. As none of the patients presented with recurrent

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acute pancreatitis of biliary origin, we propose the single-stage management as an effective method. Finally, although financial implications do not constitute the aim of the current study, it is well-known that the single-stage laparoseopic management for CBD stones clearance (compared to the two-stage management),^'' as well as the single hospitalization (compared to discharge and planned readmission later on),28 constitute cost-effective therapeutic modalities, and this parameter might be taken under consideration in the treatment of uncomplicated mild acute biliary pancreatitis. In conclusion, in patients suffering from uncomplicated mild acute biliary pancreatitis, a single-stage definitive laparoseopic management for both gallstones and CBD stone(s) eradication is feasible, effective, and possibly cost-effective and 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 fails to resolve the problem. REFERENCES 1. Sargen K, Kingsnorth AN. Management of gallstone pancreatitis: effects of deviation from clinical guidelines. J Pancreas 2001 ;5:317-22. 2. Way LW. Biliary tract. In: Way LW, ed. Current Surgical Diagnosis and Treatment, 10th Ed. Norwalk, CT: Appleton-Lange, 1994, pp 537-66. 3. Uhl W, Muller CA, Krahenbuhl L, et al. Acute gallstone pancreatitis. Timing of laparoseopic cholecystectomy in mild and severe disease. Surg Endosc 1999;13:1070-6. 4. Moore EM. A useful mnemonic for severity stratification in acute pancreatitis. Ann R Coll Surg Engl 2000;82:16-7. 5. Folsch UR, Nitsche R, Ludtke R, et al. German Study Group on Acute Biliary Pancreatitis. Early ERCP and papillotomy compared with conservative treatment for acute biliary pancreatitis. N Engl J Med 1997;336:237-42. 6. British Society of Gastroenterology. United Kingdom guidelines for the management of acute pancreatitis. Gut 1998;42(Suppl 2):S1-13. 7. Pellegrini CA. Surgery for gallstone pancreatitis. Am J Surg 1993;165:515-8. 8. Dube MG, Lobo DN, Rowlands BJ, et al. Audit of acute pancreatitis management: a tale of two hospitals. J R Coll Surg Edinb2001;46:292-6. 9. Barnard J, Siriwardena AK. Variations in implementation of current national guidelines for the treatment of acute pancreatitis: implications for acute surgical service provision. Ann R Coll Surg Engl 2002;84:79-81. 10. Toh SK, Phillips S, Johnson CD. A prospective audit against national standards of the presentation and management of acute pancreatitis in the South of England. Gut 2000;46:239^3. 11. Senapati PS, Bhattarcharya D, Harinath G, et al. A survey of the timing and approach to the surgical management of chole-

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