Timing of laparoscopic surgery in gallstone pancreatitis
E. Tang, S. C. Stain, G. Tang, E. Froes and T. V. Berne
Department of Surgery, University of Southern California School of Medicine, Los Angeles, USA.
OBJECTIVE: To study the effect of the timing of laparoscopic
cholecystectomy following acute gallstone pancreatitis. SETTING:
University-based county teaching hospital. DESIGN: Retrospective case
series. PATIENTS: One hundred forty-two patients with gallstone
pancreatitis treated by laparoscopic cholecystectomy between April 1991 and
September 1993. There were 16 men and 126 women, with a mean age of 39.5
years. The mean serum amylase level at admission was 1616 U/L. All patients
were operated on more than 48 hours after admission, after clinical and
biochemical resolution of pancreatitis. Preoperative endoscopic retrograde
cholangiopancreatography was performed in 25 patients (more than 48 hours
after admission), with common bile duct stones being identified and removed
in 10. RESULTS: Twenty patients had three or more Ranson's criteria. Of
these, nine had laparoscopic cholecystectomy attempted within the first
week of admission. Six (67%) of these patients required conversion to open
procedures (two for common bile duct exploration, one for repair of a
common hepatic duct injury, and three for anatomic distortion due to
inflammation). The mean postoperative stay of the nine patients was 5.4
days. The other 11 patients with three or more Ranson's criteria were
operated on after 1 week, and only two required conversion to open
cholecystectomy (18%). The mean postoperative stay in these 11 patients was
2.3 days. The difference in conversion rate approached but did not reach
statistical significance (P = .08). The postoperative stay, however, was
significantly shorter in the group of patients who underwent late
operations (P = .03). There were 122 patients with fewer than three
Ranson's criteria. In this group, there was no difference in length of
postoperative stay between patients operated on earlier and those operated
on later (2.4 vs 3.9 days; P = .49; n = 74 and n = 48, respectively). Of
these 122 procedures, eight were converted to open procedures (6.6%). There
was no significant difference in conversion rates in these patients
regardless of whether they were operated on earlier or later. CONCLUSIONS:
Based on these data, we believe, first, that laparoscopic cholecystectomy
is safe in patients recovering from gallstone pancreatitis (mortality rate,
0%; bile duct injury, 0.7%). Furthermore, early operation can safely be
recommended in patients with mild pancreatitis. However, in patients with
three or more Ranson's criteria, operation during the first week following
admission is associated with an increase in operative complications, an
increased rate of conversion, and longer postoperative stays.
