Gallstone Pacreatitis Does Not Always Require ERCP Prior to Cholecystectomy.
Abstracts
|
Background: The routine preoperative use of endoscopic retrograde cholangiopancreatography (ERCP) in gallstone pancreatitis is controversial. Several randomized controlled studies support the use of early ERCP in patients with signs of obstructive jaundice and severe pancreatitis. However, in patients with mild to moderate pancreatitis and no signs of obstruction, the utility of routine early ERCP in doubt. Method: We reviewed the records of patients admitted for gallstone pancreatitis at Harper University Hospital and Detroit Receiving Hospital. Of the 114 patients identified, 74 had preoperative ERCP, and 40 had no ERCP prior to cholecystectomy. We evaluated the following: length of stay (LOS), complications, worsening pancreatitis, incidence of CBD stones, and mortality. In addition, we looked at factors indicative of the presence of a common bile duct (CBD) stone and calculated the positive predictive value (PPV) and negative predictive value (NPV). Results: Preoperative ERCP was significantly associated with a length of stay greater than 6 days. 71.6% of patients who underwent preoperative ERCP followed by cholecystectomy had a LOS = 6 days whereas 28.6% of those who directly underwent cholecystectomy had a LOS = 6 days (X2=4.913, p=0.027 95%, CI= 0.041-0.379). Predictors of the presence of CBD stones are listed. In the group with no ERCP, the rate of unidentified CBD stones was 1/42 (2.3%)--use of predictive lab values would have identified this patient. In the 74 patients with preoperative ERCP, 11 had CBD stones; 10 of these would have been identified by the laboratory criteria, and the additional 1 had ultrasonographic identification of the CBD stone. Thus there were no cases of occult stones. There were no instances of worsening pancreatitis or any increased mortality in either group. Conclusion In cases of mild to moderate gallstone pancreatitis, the presence of elevated alkaline phosphatase, bilirubin, and ALT, supplemented with ultrasonographic findings can be used to select patients who require preoperative ERCP. The remainder can be taken directly for a laparoscopic cholecystectomy. |
