Laparoscopic cholecystectomy is one of the most frequently performed procedures in worldwide general surgery departments. One of the usual indications is acute pancreatitis because of gallstones. Gallstones are the most frequent cause of acute pancreatitis (35%). When to perform the cholecystectomy depends on the severity of pancreatitis.
First, the diagnosis of acute pancreatitis is based on the presence of at least two of the following three factors:
Typical clinical presentation
Serum amylase or serum lipase 3x times the upper limit of normal
Imaging findings in abdominal CT scan
Important to know is that the magnitude of the increase in amylase value does not correlate with severity. Additionally, a greater increase in amylase value is found in biliary pancreatitis than in alcohol-induced pancreatitis. However, this cannot be used to distinguish between the two etiologies.
Second, the next step is to define the severity of acute pancreatitis. This helps doctors anticipate complications and promote the correct treatment and surveillance. Because clinical assessment is associated with low sensitivity, there are several scores to help surgeons assess severity. Severe pancreatitis comprises about 20-30% of cases and has a hospital mortality rate of up to 15%. There are several scores to define the severity. Ranson’s Criteria and Atlanta Classification are both classification systems for acute pancreatitis. The former is well correlated with morbidity and mortality but can only be used once and severity can only be determined at 48h. The latter, the Atlanta score, is commonly used today and is presented in the table.
In case of mild pancreatitis, the patient should be submitted to laparoscopic cholecystectomy during the same event, usually within one week. In severe (and moderately severe) pancreatitis, cholecystectomy must be postponed for several months because of the high surgical risk for the patient. As stated in the WSES statement from 2019 “in acute gallstone pancreatitis with peripancreatic fluid collections, cholecystectomy should be deferred until fluid collections resolve or stabilize and acute inflammation ceases”. This is the best way of achieving good outcomes, I think.
Last December a female patient was admitted to the Hospital CUF Coimbra with severe acute biliary pancreatitis without jaundice, with normal bilirubin and phosphatase alkaline, with a CT scan showing a peripancreatic (inferior) fluid collection, and portal vein thrombosis. Medical treatment was initiated. Ten days later the patient was discharged home only on anticoagulant therapy. She was referred to general surgery consultation, and since the first consultation, she has been asymptomatic, with blood tests (including amylase, lipase, bilirubin, and phosphatase alkaline) within normal range. The first follow-up CT scan (one month later) showed a decrease in the peripancreatic fluid collection, but partial portal vein thrombosis was still present. At three months follow-up, the peripancreatic collection was even smaller, and the portal vein thrombosis was now absent. Anticoagulant medication was stopped (3 months for a secondary VTE event with recanalization) and another CT scan was scheduled in three months. At 6 months, the CT scan showed a gallbladder with stones, normal common bile duct, no peripancreatic collections, and normal blood flow through the portal vein with no signs of thrombosis. There were no symptoms and no jaundice. Blood tests were normal. The patient was then submitted to laparoscopic cholecystectomy (6 months after severe acute pancreatitis). Surgery was uneventful, without finding significant adhesions, fibrosis, or residual local inflammation.
The time passed since the severe acute event and the surgery, keeping a strict diet, was crucial to operate in a favorable environment to decrease the risk of complications. Knowing when not to operate and knowing how to keep patients’ anxiety levels down while waiting, is crucial for offering the patients the best treatment strategy.
The following video shows the above-mentioned patient's cholecystectomy after severe acute pancreatitis, performing a smooth dissection and respecting the critical view of Strasberg. Enjoy!
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Advised bibliography:
Mulholland MW, Lillemoe K, Doherty GM, Maier RV, Simeone DM, Upchurch GR, editors. Greenfield’s Surgery. Scientific Principles & Practice. Fifth Edition. Philadelphia: Lippincott Williams & Wilkins. 2011.
Dr. Carlos Eduardo Costa Almeida
General Surgeon
#pancreatitis #pancreas #gallstones #biliarypancreatitis #severepancreatitis #ranson #atlanta_classification #cholecystectomy #gallbladder #laparoscopic_cholecystectomy #minimallyinvasive #laparoscopy
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