Objective
To explore the selection of the timing of laparoscopic cholecystectomy LC for acute biliary pancreatitis.
Methods
We retrospectively analyzed 41 cases of acute biliary pancreatitis admitted between May 2006 and May 2009 for treatment and selection of the timing of LC surgery.
Results
Thirty-seven of the 41 cases in this group were treated conservatively, and individualized treatment plans were developed according to the degree of pancreatic inflammation or imaging and the local inflammation of the gallbladder after the pancreatitis had healed. LC was performed from two weeks to three months after the healing of pancreatic inflammation, and all of them successfully completed the surgery without intermediate openings, no side injuries, and no complications, and all of them recovered successfully, with an average hospital stay of 6.2 days and no recurrence at a follow-up of 3 months to 3 years.
Conclusion
Acute biliary pancreatitis is safe and feasible with active conservative treatment, individualized treatment plan, and selection of appropriate surgical timing for LC surgery, and there is no need to overly restrict the operation time to avoid aggravating the disease with early surgery and overemphasizing the time resulting in recurrence of pancreatitis in the interoperative period, as long as it is carefully operated.
LC surgery is still a safe and feasible surgical procedure, and its minimally invasive nature will be more conducive to patient recovery.
1. Data and methods
1.1 Clinical data.
There were 41 cases in the group, including 13 males and 28 females, aged 16 to 78 years old, with an average age of 48.6 years. The time from onset to consultation was 2h~7d, 41 patients had sudden onset of epigastric pain, abdominal distension, nausea, vomiting, 39 cases with pain radiating to the back of shoulder and waist, physical examination: body temperature was >37.5℃, there was abdominal distension, middle and upper abdominal pressure pain, Murphy’s sign (+) in some cases, local rebound pain, imaging examination: ultrasound in 33 cases suggested acute attack of chronic calculous cholecystitis, pancreatic Parenchymal echogenic enhancement, edema, some cases with peripancreatic and abdominal exudate, 8 cases with gas interference showing poorly, common bile duct internal diameter 0.5-1.5 cm, flocculent deposits or punctate strong light spots in the common bile duct in 29 cases, 6 cases with CT or MRI confirmed pancreatic edema, punctate focal necrosis, peripancreatic exudate, and abdominal fluid accumulation.
Laboratory tests: 41 cases had elevated blood and urine amylase, some cases were accompanied by elevated serum bilirubin and elevated serum transaminases, and the diagnosis of acute biliary pancreatitis was confirmed by excluding factors such as alcohol consumption, a history of chronic calculous cholecystitis, predisposing factors such as poor diet, physical diagnosis, imaging and laboratory tests were all in accordance with the criteria of acute pancreatitis.
1.2 Surgical timing selection.
All cases were treated according to acute pancreatitis, with non-surgical treatment measures such as diet abstinence, gastrointestinal decompression if necessary, broad-spectrum antibiotics, inhibition of pancreatic secretion, and antispasmodic analgesia. 34 cases had symptom relief, no fever, recovery of gastrointestinal function, blood and urine amylase decreased to normal, serum transaminases and bilirubin all basically decreased to normal, and imaging confirmed that the internal diameter of the common bile duct was not wide and there were no stones, of which 22 cases had jaundice or common bile duct All 22 cases had jaundice or widening of the internal diameter of the common bile duct ≥0.8 cm were confirmed by MRCP without stones. 31 cases underwent LC from 1 week to 4 weeks after the onset of the disease, and 6 cases underwent LC electively at a later stage of the disease due to severe inflammation of the pancreas and estimated difficulties in early surgery.
2. Results
In this group of 37 cases of LC surgery, the average operation time was 10 min~55 min, and all of them completed the operation successfully, but most of them had different degrees of adhesions in the gallbladder, especially in the gallbladder triangle, and intraoperative bleeding was increased compared with other LC cases, about 30 ml~150 ml (the average of other LC cases was about 5 ml~10 ml), and some cases with large trauma, wide separation, and more exudation were left in place. The abdominal drainage tube was left in place for 24h~72h, and those with stable vital signs could get out of bed after several hours of postoperative anesthesia wakefulness, and all cases were required to eat after 48h postoperatively, and the hospital stay was 5~15 days, with an average of 6.2 days, without complications and side injuries. There was no recurrence at the follow-up of 3 months~3 years.
3. Discussion
In recent years, with the increasing incidence of chronic calculous cholecystitis, the incidence of acute biliary pancreatitis is also increasing year by year, and biliary pancreatitis accounts for about 60% of acute pancreatitis. The common channel is blocked by microscopic stones of the gallbladder, and the reflux of bile into the pancreatic duct is the initiating factor of cholestatic pancreatitis, which can be manifested as obstructive cholangitis in the acute stage of cholestatic pancreatitis.
However, through conservative treatment, the local inflammation subsides, the obstructive microstones are discharged, and most of the obstructive cholangitis can be relieved. With the bile sludge, the microstones in the bile duct are discharged, and the dilated bile duct is retracted. With the development of modern imaging technology, most of the preoperative ultrasound or MRCP can exclude the common bile duct stones and avoid unnecessary bile duct exploration, and LC can be performed safely.
We believe that in cases of acute biliary pancreatitis, individualized treatment plans should be developed without imposing a time limit for surgery to avoid aggravating the disease by premature surgery or excessively limiting the prolonged surgery time leading to recurrence of pancreatitis in the interval to be operated, and it is safe and feasible to choose the appropriate surgical timing for LC surgery, which is more conducive to patient recovery due to the minimally invasive nature of LC and has more obvious The advantages of LC in the treatment of acute biliary pancreatitis are more obvious.