Acute gallstone pancreatitis: best timing for biliary surgery

The timing of biliary surgery in patients who have pancreatitis secondary to cholelithiasis is debatable. Of 523 patients admitted for acute pancreatitis between 1969 and 1978, 114 had gallstones for which an operation was performed, early and late operation respectively in 98 patients. Complications occurred in 12 of the 114 patients and 7 patients died. Significantly more deaths occurred in the group who had an immediate operation (n = 5). In the group who had an operation more than 7 days after the amylase returned to normal, recurrent pancreatitis developed in 5 patients, 1 of whom died. It is concluded that immediate operation does increase mortality, and so may delay longer than 7 days after the amylase returned to normal.     

胆源性急性胰腺炎的临床分型与手术时机的选择

目的 探讨胆源性急性胰腺炎（GAP）的临床分型与手术时机的选择。方法 对109例GAP患者的临床资料进行回顾性分析。结果及结论 按壶腹部有无梗阻及胰腺炎的严重程度，将GAP分为4型并用不同方法处理：（1）轻症非梗阻型，以非手术治疗为主；（2）轻症梗阻型，自发病起观察约36h，如梗阻仍未解除需早期手术，如梗阻解除则继续非手术治疗；（3）重症非梗阻型，以非手术治疗为主，并按胰腺坏死是否并发感染决定其是否手术；（4）重症梗阻型，宜行EST及时解除梗阻，如无此条件，应在短期支持治疗后早期手术，注意；非手术治疗中如出现胆囊或胆道化脓性炎症宜早期手术；经非手术治疗度过急性期的患者，应限期手术解决胆石病。     

急性胆源性胰腺炎的手术时机及手术方法

目的:探讨急性胆源性胰腺炎（ABP）的手术时机及手术方式。方法:对近2年以来收治的59例急性胆源性胰腺炎患者的临床资料进行回顾性分析。结果:36例非梗阻型ＡBP，经非手术治疗3～7 d症状缓解后行LC术后治愈。15例轻症梗阻型ABP，经保守治疗6～8h症状无缓解急诊行ERCP+EST+取石,术后均行鼻胆管引流（ENBD）治疗10～14 d，其中13例后行LC术、2例既往已行胆囊切除+胆总管探查手术治愈出院。8例重症梗阻型ＡBP伴胆管炎者，均急症行ERCP+EST+取石+ ERCP+ENB(P)D,其中1例暴发性胰腺炎伴多器官功能衰竭，入院后24 h内死亡；7例术后再经治疗10～14 d，后行LC术治愈出院。结论:非梗阻型ABP，应先保守治疗再手术；轻症梗阻型ABP，如经保守治疗无效需急症行ERCP+EST+取石+ ENB(P)D,后再行LC术；重症梗阻型SBP伴胆管炎应急症行ERCP+EST+取石+ERCP+ENB(P)D,术后病情稳定后再行LC术。     

Timing of surgery for acute gallstone pancreatitis

One hundred four consecutive patients with acute gallstone pancreatitis underwent biliary surgery. The relationships between the timing of surgery, the severity of pancreatitis, and the surgical outcome were examined. Patients were divided into three groups according to the timing of surgery and into four groups according to the gross pancreatic pathologic characteristics observed at operation. Patients who underwent surgery early tended to have a higher incidence of common bile duct stones and more severe forms of pancreatitis; however, neither the timing of surgery nor the severity of pancreatitis had a significant impact on surgical outcome. Other factors, such as the level of serum amylase on admission and presence or absence of choledocholithiasis, did not significantly influence the natural history of the disease or the outcome of surgical therapy, whereas advanced age was associated with higher morbidity. Hemodynamic status and the overall condition of the patients were more important than either the timing of surgery or the gross pathologic characteristics of the pancreas in determining surgical outcome. We conclude that the timing of surgery is not a critical factor in the outcome of surgery for acute gallstone pancreatitis. Provided that the patient is stable and has no medical contraindications, surgery on the biliary tract can be performed safely at any time after initial resuscitation of the patient and confirmation of diagnosis.     

胆源性胰腺炎手术时机的选择及术后处理

目的 探讨胆源性胰腺炎(GP)的手术时机及术后处理。方法 分析30例GP的临床资料。结果 轻型 GP 24例采用非手术疗法治愈。24例轻型胰腺炎痊愈后,再行胆道手术 20例,无手术并发症。重型 GP 6例,其中4例急诊手术治疗,均治愈,但术后均有不同程度的并发症。另2例因全身情况不允许手术,行非手术治疗,治愈1例,死亡1例。结论 轻型GP应待急性发作缓解后手术,术后处理与一般的胆道疾病的相同。重型GP,若全身条件许可,应积极行外科手术治疗,并需重视术后处理。     

The impact of timing of cholecystectomy following gallstone pancreatitis

IntroductionCurrent guidelines for the management of acute gallstone pancreatitis recommend cholecystectomy as definitive treatment during primary admission or within 2 weeks of discharge, with the aim of preventing recurrent pancreatitis. However, cholecystectomy during the inflammatory phase may increase surgical complication rates. This study aimed to determine whether adherence to the guidelines prevents recurrent pancreatitis while minimising surgical complications.MethodsMulti-centre review of seven UK hospitals, indentifying patients presenting with their first episode of gallstone pancreatitis between 2006 and 2008.ResultsA total of 523 patients with gallstone pancreatitis were identified, of which 363 (69%) underwent cholecystectomy (72 during the primary admission or within 2 weeks of discharge; 291 following this). Overall, 7% of patients had a complication related to cholecystectomy of which a greater proportion occurred when cholecystectomy was performed within guideline parameters (13% vs 6%; p = 0.07). 11% of patients were readmitted with recurrent pancreatitis prior to surgery, with those undergoing cholecystectomy outside guideline parameters being most at risk (p = 0.006).ConclusionThis study suggests cholecystectomy within guideline parameters significantly reduces recurrence of pancreatitis but may increase the risk of surgical complications. A prospective randomised study to assess the associated morbidity is required to inform future guidelines.     

急性胆石性胰腺炎发病原因和手术时机探讨

通过６０例急性胆石性胰腺炎资料分析，结合文献探讨了ＡＧＰ的发病原因与手术时机。结果显示：共同通道具备了胆汁返流的解剖学基础；胆石阻塞胆总管下端、感染胆汁返流入胰管；肠胰返流及胰管梗阻均为ＡＧＰ发病的重要因素。     

The optimal timing of laparoscopic cholecystectomy in mild gallstone pancreatitis

The optimal timing of laparoscopic cholecystectomy (LC) in patients with biliary pancreatitis is not standardized. Our objective was to determine if patients with mild gallstone pancreatitis (three or fewer Ranson's criteria) can safely proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving. We reviewed the charts of all adults admitted to our institution with gallstone pancreatitis from January 1999 until June 2002 who had LC performed by either surgeon 1 (group 1) or surgeon 2 (group 2). Surgeon 1 preferred to delay surgery until normalization of amylase and complete resolution of abdominal tenderness, whereas surgeon 2 preferred to proceed to LC as soon as serum amylase was decreasing and abdominal tenderness was improving. The two groups were well matched for sex, age, Ranson's criteria, and percentage requiring endoscopic retrograde cholangiopancreatography. Average total hospital stay was 4.7 days in group 1 versus 3.5 days in group 2 (P = 0.01). There was no statistical difference in complication rate between the two groups (10% in group 1 vs 11% in group 2, P = 0.12). The data suggest that hospital stay can be shortened with no increased complication rate if patients with mild biliary pancreatitis proceed to LC as soon as serum amylase is decreasing and abdominal tenderness is improving.     

急性胆源性胰腺炎167例外科治疗分析

目的　探讨急性胆源性胰腺炎 (AGP)的合理诊治方法。方法　回顾分析 167例AGP资料并将其分为重型组 ( 4 9例 )和轻型组 ( 118例 ) ,分析胆道梗阻情况、外科手术时机及术后并发症对死亡率的影响。结果　入院时有否梗阻病死率无差别 (P >0 .0 5 ) ,梗阻时间 >48h者病死率高于 <48h者 ( P <0 .0 5 ) ;重症AGP早期手术死亡率高于延期手术 ( P <0 .0 5 ) ;轻症AGP早晚期手术间病死率无统计学差异 (P >0 .0 5 ) ;术后胰腺感染和MODS是AGP的主要死因。结论　入院时壶腹部梗阻不是AGP手术指征 ,若梗阻持续不能解除 ( >48h)则考虑手术 ;重症AGP慎行早期手术 ;预防并及时处理并发症是降低AGP病死率的关键。     

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目的探讨胆源性胰腺炎(GP)病人胆道结石的处理方式和时机。方法回顾性分析1998年5月至2003年6月期间89例GP病人的处理方式和时机结果腹腔镜胆囊切除术(LG)的比例逐渐增加(48％)，剖腹胆道手术却逐渐减少(52％)，尤其是剖腹胆总管探查术(12％)，但胆总管结石探查的阳性率却明显增加(100％)。术前进行ERCP检查的比例仅0～4％，但MRCP的比例增加到32％。极少数病人(0～8％)需要行内镜括约肌切开(Ⅸ汀)治疗。结论采用微创技术处理GP病人胆道结石的方式逐渐增加。GP病人胆道结石的最佳处理时期是胆道和胰腺的炎症得到控制后，大多数病人需要1～3周。对B超不能确诊的胆总管结石，应首选脉CP检查，慎用逆行性胰胆管造影术(ERCP)。     

30例重症胆源性胰腺炎延期手术探讨

目的　探讨重症胆源性胰腺炎 (GP)的手术时机。方法　对 1 995年 1月～ 1 999年 1 2月收治的 30例明确诊断为重症GP患者延期手术和病死率进行系统的回顾性分析。结果　 2例因梗阻性化脓性胆管炎早期急诊手术 ,术后 1例死于心衰。非手术治疗过程中 1例死于多器官功能衰竭。延期手术 2 7例 ,2例分别死于多器官功能衰竭和真菌性败血症。术后并发症 2例 ,分别是胰瘘和胰周残余脓肿。延期手术病死率和并发症发生率分别是 1 0 .0 %、6 .7%。结论　重症GP应首先行非手术治疗 ,待渡过急性期 ,一般于起病 3周后在同一住院期间延期手术 ,若非手术治疗过程中出现梗阻性化脓性胆管炎、胰腺坏死组织并发感染 ,应早期急诊手术。延期手术能保证较低的病死率     

重症胰腺炎手术指征和手术时机的探讨

目的 探讨重症且腺炎的手术指征和手术时机。方法 回顾性分析８２例重症胰腺炎的治疗情况,其中行非手术治疗１０例、早期手术４４例、延期手术２８例。结果 本组总并发症发生率为２４％、总病死率为１８％。非手术组１０例均痊愈,并发症发生率为１０％;早期手术组死亡５例,并发症经和病死率分别为１４％和１１％;延期手术组死亡１０例,并发症发生率和病死率分别为４６％和３６％,两组相比差异有显著意义（Ｐ＜０.０１、Ｐ＜０.０５）。延期手术组中,无明显感染者其并发症发生率和病死率明显低于有严重感染及重要器官功能不全者（Ｐ＜０.０１、Ｐ＜０.０５）。结论 早期手术治疗对于一些重症胰腺炎患者仍然是必需的。胰腺坏死广泛者宜在发生严惩感染前进行手术。     

Acute gallstone pancreatitis

BACKGROUND: In acute gallstone pancreatitis, the ideal point in time for laparoscopic cholecystectomy with special reference to the severity of the disease has been prospectively analyzed. METHODS: A total of 77 patients with biliary acute pancreatitis were admitted between November 1993 and July 1998 (37 men and 40 women; mean age, 63 years; median Apache II score, 13.3) and staged by contrast-enhanced computed tomography findings as having edematous or necrotizing disease. RESULTS: In 48 patients, laparoscopic cholecystectomy was found to be possible: 35 patients (73%) with mild and 13 patients (27%) with severe acute pancreatitis. The overall success rate was 79% (38 of 48 patients), with 85% (30 of 35 patients) and 62% (8 of 13 patients) having mild and severe disease, respectively. Median duration of time between onset of symptoms and surgery was 10 days (range, 4-19 days) in edematous and 14 days (range, 7-29 days) in necrotizing pancreatitis (p = 0.0353). Operating time (median, 80 min) and hospital stay (median, 5 days) were almost the same in both groups. Total morbidity was 8%, with no mortality. CONCLUSIONS: Laparoscopic cholecystectomy with preoperative endoscopic common bile duct clearance is recommended as a treatment of choice for biliary acute pancreatitis. In mild disease, this is performed safely within 7 days, whereas in severe disease, especially in extended pancreatic necrosis, at least 3 weeks should elapse because of an increased infection risk.     

Management of gallstone pancreatitis

The clinical course of 143 patients with gallstone pancreatitis is reviewed. Thirty-one patients (22%) had three or more positive prognostic factors on admission and 24 (77%) of these had a complicated course. Thirteen patients died, giving an overall mortality rate of 9%. Patients were divided into three groups on the basis of performance and timing of surgery. In group 1 (n = 56), surgery was undertaken during the first admission with acute pancreatitis; eight of these patients had a complicated course and three died. In group 2 (n = 40), biliary surgery was deferred to a subsequent admission; none of these patients died but 10 experienced further attacks of pancreatitis while awaiting reoperation. Group 3 patients (n = 47) did not undergo surgery; nine patients were diagnosed as having gallstone pancreatitis for the first time at autopsy, five refused operation, seven were lost to follow-up, six were dealt with by endoscopic sphincterotomy, and in 20 cases surgery was not considered appropriate because of general debility or advanced age. Despite the zero mortality rate in group 2, it is advocated that biliary surgery be carried out during the index hospital admission. Endoscopic sphincterotomy can now be considered as an alternative to cholecystectomy and duct clearance in the elderly and unfit, and may be used as a preliminary manoeuvre when severe acute pancreatitis fails to settle promptly on conservative management.     

Pathogenesis of gallstone pancreatitis

Patients with gallstone pancreatitis have a high incidence of factors predisposing them to bile reflux and they do well after cholecystectomy. These findings are not evident in other forms of pancreatitis. It is concluded that bile from a stone-filled gallbladder and an anatomic predisposition are important initiating factors in gallstone pancreatitis.     

Sulindac-induced acute pancreatitis mimicking gallstone pancreatitis

Two patients with sulindac-induced acute pancreatitis presented clinically with abdominal pain, right upper-quadrant tenderness, markedly increased serum amylase values, and hyperbilirubinemia, findings initially suggestive of gallstone pancreatitis. Ultrasound examinations were negative for gallstones. One patient was inadvertently treated two years later with sulindac with recurrence of abdominal pain, marked hyperamylasemia, and jaundice. Clinical resolution was rapid with each episode following discontinuation of sulindac.     

重症急性胰腺炎的早期处理和手术时机

重症急性胰腺炎(SAP)是一种来势凶险的急腹症，因其起病急骤、病情变化迅速且复杂多变，临床诊治难度大，而成为医学界同仁们关注的热点和治疗决策的难点。综观近30年来我国重症急性胰腺炎治疗徘徊的历程，从上个世纪70～80年代主张早期手术，甚至SAP一经诊断就立即手术及过分强调手术切除的彻底性，     

胆源性胰腺炎手术时机的探讨

目的探讨胆源性胰腺炎（ＧＰ）的手术时机。方法采用统计学方法分析了５３例ＧＰ的临床资料。结果早期手术组（入院４８小时内）及延期手术组（入院４８小时后）并发症发生率分别为２９．２０％和３．５０％（Ｐ＜０．０５）;死亡率分别为８．３０％和０（Ｐ＜０．０５）。ＡＰＡＣＨＥ－Ⅱ记分≤８的轻型ＧＰ死亡率与手术时机无关,但早期手术组的并发症发生率（１１．１０％）及胆总管探查率（９１．７０％）明显高于延期手术组（Ｐ＜０．０５）。ＡＰＡＣＨＥ－Ⅱ记分＞８的重型ＧＰ并发症发生率及死亡率与手术时机有关,即早期手术组明显高于延期手术组。结论轻型ＧＰ应待急性发作缓解后延期手术;重型ＧＰ应采用延期与个体化相结合的处理原则。