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.