Title: Study of Outcome of Early Vs Delayed Laparoscopic Cholecystectomy in Mild and Moderate Acute Gallstone Pancreatitis
Authors: Prince Muzafer Wani, Raheeb Ahmad Shah, Sajad Ahmad Para, Parvez Ahmad Bhat, Arsalan Un Nisa
DOI: http://dx.doi.org/10.18535/jmscr/v3i8.44
DIDS : 08.2015-XXXXXXX
Objectives: The aim of our study was to compare the outcome of early (<2 weeks) versus delayed (>2weeks) laparoscopic cholecystectomy in patients of mild and moderate acute gallstone pancreatitis. Methods: The present study was carried for a period of two years (2012-2013).The study was a prospective one, and the admitted patients were stabilized, conservative management was continued till patients clinical profile, laboratory and biochemical parameters indicate termination of acute attack of pancreatitis, and CT was done within 48 hours of admission. After termination of acute attack of pancreatitis patients were randomly allocated into two groups using proper statistical technique viz. Group A and Group B. Group A included the patients of mild and moderate gallstone pancreatitis in whom early laparoscopic cholecystectomy was performed (within two weeks of index admission), Group B included the patients of mild and moderate gallstone pancreatitis in whom delayed laparoscopic cholecystectomy was performed (after two weeks of index admission). Any CBD stone detected preoperatively was subjected to endoscopic retrieval before taking up the patient for surgery. The two groups were compared as per the preset proforma and the difference between the two groups was statistically analyzed. The end point of study was follow-up upto one year. Results: In each group 40 patients were operated via 4 port laparoscopic cholecystectomy. The mean age in Group A was 41.9±10.24 years and in Group B was 42.025±10.56 years, p-value=0.957. The cases were included in the study irrespective of their sex. Out of 80 cases 7 and 9 were males in Group A and B respectively and 33 and 31 were females in Group A and B respectively, p-value = 0.576. Modified CECT severity index was used to assess severity of acute pancreatitis, Group A had a mean score of 3.1±1.19 and Group B had mean score of 3.2±1.27 p-value=0.857 and there was no statistically significant difference between two groups. ERCP was used before taking up cases for surgery where CBD calculi where detected. 15% in Group A and 20% in Group B underwent pre-operative ERCP and the difference was statistically not significant p-value=0.769. There was no recurrence of pancreatitis and cholecystitis in group A, however 15% cases of group B had recurrent pancreatitis or cholecystitis, p-value 0.02.There was no mortality in our study in either of the two groups. Morbidity was studied in terms of intraoperative and postoperative complications in a preset proforma. Intraoperatively there was no visceral, diaphragmatic or CBD injury in either groups, however 2 (5%) cases of Group A and 1 (2.5%) cases in Group B had intraoperative bleeding but the difference was not statistically significant. Postoperatively 11 complications were met in Group A and 8 complications were met in Group B but results were not statistically significant. The hospital stay and loss of work days was significantly shorter in Group A cases in comparison with Group B cases p-value <.0001. Conclusion: Early laparoscopic cholecystectomy is best to prevent recurrent attacks of pancreatitis and cholecystitis and it reduces the total hospital stay and loss of work days without increasing the intraoperative and post operative morbidity. Keywords: Gallstones, pancratitis, early cholecystectomy, delayed cholecystectomy. 1. Symmers W.S.C. Acute alcoholic pancreatitis. Dublin J Med Sci 1917; 143: 244-247. 2. Acosta JM, Ledesma CL. Gallstone migration as a cause of acute pancreatitis. N Engl J Med 1974; 290: 484-7 3. Carroll JK, Herrick B, Gipson T, Lee SP. Acute pancreatitis: diagnosis, prognosis, and treatment. Am Fam Physician 2007; 75: 1513-1520. 4. Schietroma M, Carlei FLezoche E, Rossim, Liakos CH, Mattucci S et al. Acute biliary pancreatitis: staging and management. Hepatogastroentrology 2001; 48: 988-993. 5. Goldacre MJ, Roberts SE. Hospital admission for acute pancreatitis in an English population, 1963-98; database study of incidence and mortality. Br Med J 2004; 328: 1466-1469. 6. Brivet FG, Emilie D, and Galanaud P. Pro- And anti-inflammatory cytokines during acute severe pancreatitis: an early and sustained response, although unpredictable of death. Parisian Study Group on Acute Pancreatitis. Crit Care Med 1999; 27(4): 749-55. 7. Agarwal N, Pitchumoni CS and Sivaprasad AV. Evaluating tests for acute pancreatitis. Am J Gastroenterol 1990; 85(4): 356-66. 8. Marx JA, Hockberger RS, Walls RM et al. Rosen’s Emergency Medicine: Concepts and Clinical Practices. 7th ed. Philadelphia: Mosby/Elsevie; 2010. 9. Morgan Rosenberg, Ariel Klevan and Eran Shlomovitz. Acute biliary pancreatitis. Pancreatic Treatment and Complication. Gastroenterology & Hepatology 2010; 7: 495-502. 10. Mortele KJ et al. A modified CT severity index for evaluating acute pancreatitis: improved correlation with patients outcome. AJR Am R Roentgenol 2004 Nov; 183(5): 1261-5. 11. John HC, Ranson MD. The timing of biliary surgery in acute pancreatitis. Ann Surg May 1979; 654-63 12. Shikata S, Noguchi Y, Fukui T. Early versus delayed cholecystectomy for acute cholecystitis: a meta-analysis of randomized controlled trials. Surg Today 2005; 35: 553-60. 13. Stevens KA, Chi A, Lucas LC, Porter JM, Williams MD. Immediate laparoscopic cholecystectomy for acute cholecystitis: no need to wait. Am J Surg 2006; 192: 756-61. 14. Lau H, Lo CY, Patil NG, Yuen WK. Early versus delayedinterval laparoscopic cholecystectomy for acute cholecystitis: a meta-analysis. Surg Endosc 2006;20: 82-7. 15. Soffer D, Blackbourne LH, Schulman CI, et al. Is there an optimal time for laparoscopic cholecystectomy in acute cholecystitis? Surg Endosc 2007;21:805-9. 16. Frei GJ, Frei VT, Thirlby RC, McClelland RN. Biliary pancreatitis: clinical presentation and surgical management. Am J Surg 1986; 151: 170-5. 17. Taylor E, Wong C. The optimal timing of laparoscopic cholecystectomy in mild gallstone pancreatitis. Am Surg 2004; 70: 971-5. 18. Kaw M, Al-Antably Y, Kaw P. Management of gallstone pancreatitis: cholecystectomy or ERCP & endoscopic sphincterotomy. Gastrointest Endosc 2002; 56: 61-5. 19. Uhl W, Muller CA, Krahenbuhl L, Schmid SW, Scholzel S, Buchler MW. Acute gallstone pancreatitis: timing of laparoscopic cholecystectomy in mild and severe disease. Surg Endosc 1999; 13: 1070-6. 20. Schachter P, Peleg T, Cohen O. Interval laparoscopic cholecystectomy in the management of acute biliary pancreatitis. HPB Surg 2000; 11: 319-22. 21. Cameron DR, Goodman AJ. Delayed cholecystectomy for gallstone pancreatitis: re-admissions and outcomes. Ann R Coll Surg Engl 2004; 86: 358-62. 22. Alimoglu O, Ozkan OV, Sahin M, Akcakaya A, Eryilmaz R, Bas G. Timing of cholecystectomy for acute biliary pancreatitis: outcomes of cholecystectomy on first admission and after recurrent biliary pancreatitis. World J Surg 2003; 27: 256-9. 23. Christian A. Nebiker, Daniel M. Frey, Christian T. Hamel, Daniel Oertli MD et al. Early versus delayed cholecystectomy in patients with biliary acute pancreatitis. Surgery 2009; 145: 260-4. 24. Parans H, Mayo A, Paran D. Octreotide treatment in patients with severe acute pancreatitis. Dig Dis Sci.2000; 45: 2247-2251. 25. Dube MG, Beckingham IJ, Fang CS, Rowlands BJ. Audit of management of acute pancreatitis based on national guidelines. Br J Surj 2000; 87(Suppl) 1): 62-63Abstract
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