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Management of Gallstone Pancreatitis: Effects of Deviation from Clinical Guidelines

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Management of Gallstone Pancreatitis: Effects of Deviation from Clinical Guidelines JOP. J. Pancreas (Online) 2001; 2(5):317-322. Management of Gallstone Pancreatitis: Effects of Deviation from Clinical Guidelines Kevin Sargen, Andrew N Kingsnorth Department of Surgery, Plymouth Postgraduate Medical School, Derriford Hospital. Plymouth. United Kingdom ABSTRACT INTRODUCTION Context Recently published management guidelines for acute pancreatitis provide a Acute pancreatitis is a common disease with standard against which practice can be considerable morbidity and mortality [1, 2, 3]. measured. Specifically it is recommended all Epidemiological data on the disease is sparse patients with gallstone induced pancreatitis and inconsistent, but there is general have definitive clearance of gallstones within agreement that the incidence in industrialised four weeks. countries is approximately 10-20 per 105 Objective To determine if practice in our population [2, 3]. Acute pancreatitis has a institution followed these guidelines and to varied aetiology, gallstone disease and analyse the effects of delayed clearance of alcohol predominating amongst identifiable gallstones. causes. In the UK the reported incidence of Methods Seventy-six consecutive patients gallstone pancreatitis has been variable. with gallstone pancreatitis presenting within a Studies report that biliary stone disease 15 month period were prospectively studied accounts for 30 to 50% of cases of acute to compare management with national pancreatitis [2, 4, 5, 6]. guidelines and to determine rates of recurrent Although the number of patients with biliary-pancreatic disease due to delay in gallstones developing acute pancreatitis is clearance of gallstones. small [7], it is clear that even stones less than Results Only 5 of 76 patients (6.6%) had 5 mm in diameter increase the risk of operative removal of gallstones within four presenting with acute pancreatitis four fold weeks of their episode of acute pancreatitis. [8]. Furthermore it is recognised that the risk Only 34 of 76 patients (44.7%) had their of acute pancreatitis in patients with biliary gallstones removed during the follow up stone disease is reduced to that of the normal period (minimum 8 months). Fourteen of 76 population following removal of the patients (18.4%) had unplanned readmissions gallbladder and it’s stones [7]. to hospital with biliary-pancreatic disease, Recognised management of acute gallstone necessitating a total of 135 days in hospital. pancreatitis is to ensure that any Conclusions It is clear from this study that choledocholithiasis is diagnosed and cleared, guidelines for the management of gallstone with definitive eradication of gallstones by acute pancreatitis are not being met, resulting cholecystectomy. Endoscopic retrograde in high rates of readmission with related cholangio-pancreatography (ERCP) can be disease. used to diagnose and clear JOP. Journal of the Pancreas – http://www.joplink.net – Vol.2, No.5 – September 2001 317 JOP. J. Pancreas (Online) 2001; 2(5):317-322. choledocholithiasis, but eradication of maximum 25 months) to identify episodes of gallstones is by cholecystectomy recurrence of biliary-pancreatic disease (laparoscopic or open) in patients who are fit requiring hospital admission. The follow up for surgery. Choledocholithiasis can be period ended in June 1998. excluded or confirmed and treated at the same Mean age at presentation was 59.6 years time as cholecystectomy if surgical (range 18-93 years). exploration of the bile duct is undertaken. The criteria for diagnosis of acute pancreatitis Recent years have seen the publication of were: a clinical history consistent with the national disease management guidelines disease, appropriate radiological evidence, produced by sub-specialist groups and and a serum amylase level greater than 660 endorsed by other interested national U/L (Hitachi 911, Hitachi Corporation, Japan; organisations. The management of acute normal range less than 220 U/L). Aetiology of pancreatitis is the topic of one recent acute pancreatitis was classified as being due publication [9]. Within the document several to gallstones in the presence of appropriate key recommendations are made relating to radiological or ERCP findings. gallstone pancreatitis. One of these is the The progress of individuals with regard to recommendation that all patients with mild development of complications was monitored acute pancreatitis due to cholelithiasis should during their disease episode, enabling patients have definitive eradication of gallstones by to be classified as having mild disease or cholecystectomy (with bile duct clearance if severe local or systemic disease according to required) ideally within two and no longer criteria defined by the Atlanta convention than four weeks following their episode of [11]. acute pancreatitis, to prevent recurrence of The first admission of a patient with proven disease. gallstone pancreatitis was classified as the Recently published evidence suggests that index admission. Length of index admission delay in the definitive treatment of gallstones (days), time in weeks from admission to causing pancreatitis is commonplace in the endoscopic intervention (ERCP and UK. A prospective audit of the management sphincterotomy), or definitive operative of 186 patients (including 62 with gallstone clearance of gallstones (cholecystectomy) pancreatitis) presenting over one year in the were recorded. The occurrence of episodes of South of England showed that only 33% had readmission with pancreatic or biliary disease treatment of cholelithiasis within the were also recorded. suggested four weeks [10]. However it is not clear to what extent such STATISTICS delay affects rates of recurrent biliary- pancreatic disease in this group of patients. Data were analysed using simple descriptive This survey was undertaken to determine how statistics. current practice within an acute surgical unit in the UK measured up to the national ETHICS guidelines and to examine rates of recurrent biliary-pancreatic disease should there be any This was an observational study. All patients delay in eradication of gallstones. were managed in accordance with normal clinical practice. No informed consent was PATIENTS AND METHODS obtained. Seventy-six consecutive patients admitted RESULTS within a 15-month period with an episode of gallstone pancreatitis were identified and The mean length of hospital stay on the initial prospectively studied. They were followed up (index) admission was 9 days (range 1-57 for a mean of 19.4 months (minimum of 8 and days). Fifteen patients (19.7%) were classified JOP. Journal of the Pancreas – http://www.joplink.net – Vol.2, No.5 – September 2001 318 JOP. J. Pancreas (Online) 2001; 2(5):317-322. 11.8% Endoscopic Retrograde Cholangio- ERCP only Pancreatography ERCP & cholecystectomy 43.4% 22.4% Fifty of 76 patients (65.8%) had an ERCP. Open cholecystectomy & Forty-one patients (53.9%) had an ERCP CBD exploration during their initial (index) admission. Two of No treatment these patients did not have a sphincterotomy 22.4% due to technical difficulties. The other 9 (11.8%) patients had an ERCP after their Figure 1. Management of gallstone pancreatitis episode of acute pancreatitis, taking place an (n=76). average of 9.2 weeks following the initial ERCP only (n=33, 43.4%). 82.0% of patients who had an ERCP underwent this procedure during their illness (range 1-21 weeks). admission with acute pancreatitis. Thirty-three of the 76 patients (43.4%) who ERCP and laparoscopic cholecystectomy (n=17, had an ERCP and sphincterotomy did not 22.4%). Average time to definitive clearance of have definitive clearance of stones during the gallstones 14.2 weeks (range 4-33 weeks). follow up time period. Only 3 were Open cholecystectomy and CBD exploration (n=17, 22.4%). Average time to definitive clearance of considered too unfit for surgery, due to gallstones 13.4 weeks (range 3-30 weeks). obesity (2), and chronic cardiac disease (1) No treatment (n=9, 11.8%). This group had no but this still leaves 30 of 76 (39.5%) who did treatment of cholelithiasis/choledocholithiasis. This not have gallstones cleared. includes 2 patients who died during their acute disease episode. Cholecystectomy following ERCP as having severe disease according to the Atlanta convention classification [11]. Cholecystectomy was performed in only 17 of Sixty-seven of 76 patients (88.2%) had either 76 patients (22.4%) following ERCP during ERCP, ERCP followed by laparoscopic the follow up period of this study. All these cholecystectomy or open cholecystectomy were done laparoscopically. One patient had and common bile duct (CBD) exploration. definitive eradication of stones by Thirty-three of the 76 patients (43.4%) who laparoscopic cholecystectomy during their had an ERCP and sphincterotomy did not initial admission episode (length of stay: 2 have definitive clearance of stones during the weeks). In the others, average time from follow up time period. initial disease episode to cholecystectomy in Only a small proportion of patients (9 this group of patients who had had ERCP was patients, 11.8%), had no treatment at all of 14.2 weeks (range 4-33 weeks). Patients choledocholithiasis. This group consisted of 4 waited an average 10.6 weeks (range 3-24 patients with severe disease and 5 with mild weeks) following their ERCP for eradication disease and included 2 patients who died from of gallstones by cholecystectomy. their acute disease at 3 and 16 days. Three of the patients were considered too obese for Open Cholecystectomy and CBD safe surgery and 2 had
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