Clinical Science
A practical cost-effective management strategy for gallstone pancreatitis

https://doi.org/10.1016/j.amjsurg.2012.12.009Get rights and content

Abstract

Background

The purpose of this study was to evaluate the outcomes of various surgeon strategies used to evaluate and treat common duct stones (CDSs) in patients presenting with mild to moderate gallstone pancreatitis (GP).

Methods

We performed a retrospective review of patients admitted for mild to moderate GP. Data variables included laboratory values and radiology images, indications for and findings of intraoperative cholangiogram (IOC) and endoscopic retrograde cholangiopancreatography (ERCP), length of stay (LOS), and hospital charges. Data were stratified by 2 different management strategies: preoperative ERCP and then laparoscopic cholecystectomy (LC) or LC with IOC followed by selective postoperative ERCP.

Results

During this time period, 80 patients met the study criteria, 56 were treated by LC with IOC, and 24 had a preoperative ERCP performed. The incidence of CDS was 33% (n = 26). The presence of CDSs correlated with an elevated total bilirubin at admission (CDSs 3.5 mg/dL vs 2.1 mg/dL no CDSs, P < .01) and 24 hours after admission (CDS 3.2 mg/dL vs 1.5 mg/dL no CDS, P < .01). Patients who had an IOC compared with those who had preoperative ERCP had a shorter LOS (4.6 vs 5.9 days, P = .04) and lower hospital charges (US $28,510 vs US $38,620; P < .01).

Conclusions

Elevated total bilirubin at admission and 24 hours after admission may predict a patient's risk for CDS. We found that the management of uncomplicated GP with early LC and IOC results in decreased LOS and total hospital charges when compared with preoperative ERCP.

Section snippets

Methods

We conducted a retrospective review of all patients undergoing LC for GP between January 1, 2005, and December 31, 2009. Medical records were identified by searching the hospital database for all patients who underwent LC (Current Procedural Terminology [CPT] code 47562) and LC with IOC (CPT 47563) with a preoperative diagnosis of acute pancreatitis (International Classification of Diseases, Ninth Revision [ICD-9] 577.0). Patients were excluded if they were less than 18 years of age, had a

Results

A search of CPT codes 47562 and 47563 resulted in identifying 1,308 patients who underwent LC during the study period of 5 years of whom 115 (9%) had acute pancreatitis (ICD-9 577.0). All patients were older than 18 years. Five patients were excluded for a concomitant diagnosis of cholangitis (ICD-9 576.1), and another 15 patients were excluded because of severe pancreatitis (Ranson score >3). An additional 15 patients were managed with only LC and were excluded, leaving a study population of

Comments

The treatment of GP has evolved over the last 30 years with the evolution of minimally invasive surgery and interventional endoscopy. In fact, the use of open cholecystectomy with open CBD exploration for the treatment of GP is rarely performed today because this approach had higher morbidity and mortality rates. Conversely, with the advent of LC, ERCP, and LCBDE, the operative morbidity associated with GP has greatly decreased. As a result, the evolution of these new procedures has created

References (19)

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Cited by (5)

  • Routine intraoperative cholangiography is unnecessary in patients with mild gallstone pancreatitis and normalizing bilirubin levels

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    Although the rate of recurrent pancreatitis of 1.5% seen in our series is lower than that seen in the current literature, most sources still report rates of readmission to be 5% at the most.13,14 As common duct stones are said to be found in 10% to 30% of patients with gallstone pancreatitis, this low rate of recurrent pancreatitis suggests that most of these common duct stones are of minimal clinical consequence.6–8 Even if 30% of patients do in fact have common duct stones, only 5% of those patients will have a recurrent episode significant enough to warrant readmission, and a policy of routinely evaluating the bile ducts would result in the overtreatment of disease.

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    This issue is controversial and requires further investigation. Gallstones passing into the common duct are the offending agents in GSP, and although most pass spontaneously into the duodenum without incident, 7% to 28% of the time stones may remain in the common duct.21,118–121 Given sufficient evidence for choledocholithiasis coexistent with mild pancreatitis, it is safe and effective to remove the stone at the time of cholecystectomy by laparoscopic CBD exploration (LCBDE).122

  • Intraoperative cholangiography: a stepping stone to streamlining the treatment of choledocholithiasis

    2022, Surgical Endoscopy

  • Scoring System for the Management of Acute Gallstone Pancreatitis: Cost Analysis of a Prospective Study

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  • ERCP peri-cholecystectomy

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The authors declare no conflicts of interest.

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