The role of endoscopic sphincterotomy in the management of acute biliary pancreatitis

Abstract

Acute biliary pancreatitis is a serious complication of biliary calculus disease and is associated with significant morbidity and mortality. The role of endoscopic retrograde cholangiopancreatography (ERCP) in the management of acute biliary pancreatitis has been the focus of discussion in recent years. In addition, the exact role of laparoscopic cholecystectomy (LC) in the management of acute biliary pancreatitis has not yet been fully defined. In this study, we evaluated a protocol of emergency ERCP (within 24 h) for predicted severe attacks, early ERCP (within 72 h) for predicted mild attacks, and interval LC for management of acute biliary pancreatitis. We analyzed the results of treatment of 75 patients with acute biliary pancreatitis managed according to the protocol. Bedside ultrasonography at admission diagnosed 94% of all 64 patients with gallstones, but the sensitivity of visualizing choledocholithiasis was low (19%). Forty-five (60%) of them were predicted to have a severe attack by either the Ranson scoring system or glucose/urea criteria. Emergency ERCP and endoscopic sphincterotomy (ES) for identifiable common bile duct or ampullary stones were performed on all patients predicted to have a severe attack within 24 h from presentation. An early endoscopic procedure was performed on all patients predicted to have a mild attack within 72 h from presentation. ERCP was successful in 94% of all patients, and CBD stones were detected in 52 (69%) of them. ES and stone clearance were successful in all of these 52 patients. The morbidity associated with the endoscopic procedure was 3%, and there were no deaths. All except one patient survived the attack of acute pancreatitis, resulting in an overall mortality of 1%. Interval LC was performed on 46 patients, with a conversion rate of 4%. The median postoperative hospital stay after LC was 2 days, and there was no major intraoperative or postoperative morbidity or mortality. Our experience suggests that the policy of emergency ERCP for patients with predicted severe disease, early ERCP for patients with predicted mild disease, and interval LC is associated with favorable outcomes in patients with acute biliary pancreatitis. Acute biliary pancreatitis can be managed safely and effectively by a combined endoscopic and laparoscopic approach. © 2009 Springer-Verlag Berlin Heidelberg.