Figure - available via license: Creative Commons Attribution 4.0 International
Content may be subject to copyright.
Source publication
Background:
Occult biliary disease has been suggested as a frequent underlying cause of idiopathic acute pancreatitis (IAP). Cholecystectomy has been proposed as a strategy to prevent recurrent IAP. The aim of this systematic review was to determine the efficacy of cholecystectomy in reducing the risk of recurrent IAP.
Methods:
PubMed, Embase an...
Context in source publication
Similar publications
Rationale
Multiseptate gallbladder (MSG) is a rare congenital gallbladder anomaly. Between 1963 and June 2021, only 56 cases were reported. There is currently no treatment guideline for pediatric or adult cases of MSG.
Patient concerns
A 14-year-old woman visited our out-patient clinic in September 2020 for epigastric pain that last for 6 months....
Citations
... However, identification of etiology can be difficult, and up to one third of patients may have no initial cause found. There is also evidence to suggest that current diagnostic tools may miss occult biliary disease, as some patients with recurrent "idiopathic" pancreatitis may benefit from cholecystectomy (14). It is also well known that alcohol is a risk factor for pancreatitis and alters fat metabolic pathways (15) and so this also suggests alcoholic patients may be prone to having a predilection for a certain fat distribution. ...
Purpose: This study aims to investigate the relationship between visceral adiposity and the possible etiologies of acute pancreatitis. Obesity creates low-grade inflammation and evidence supports an association between obesity and inflammatory conditions such as pancreatitis. CT imaging is utilized in assessing pancreatitis severity and complications but also offers the chance to quantitatively measure visceral fat area (VFA) and subcuta-neous fat area (SFA). Given the metabolic role that fat plays, we hypothesized that different body fat distributions, as measured by these areas, may be associated with different etiologies. Further, this also allows us to explore a relationship between severity, etiology, and the fat distributions in patients with acute pancreatitis. Method: Retrospective observational cohort study of all patients admitted to a single center. The VFA, SFA, their ratio (VFA/SFA) and total fat area (TFA) were calculated using a semi-automatic algorithm. Results: 518 patients were admitted with acute pancreatitis over a three-year period. 177 patients underwent CT imaging. Gallstone pancreatitis patients had higher VFA and TFA measurements while alcoholic pancreatitis patients had lower measurements. Patients with pancreatitis with no clear cause had the lowest VFA/SFA ratio. Increasing VFA was associated with increasing severity in a univariate logistic regression model (p = 0.01 0.01) but this association diminished in a multivariate model accounting for etiology (p = 0.09). Conclusion: The pattern of fat distribution differs amongst the etiologies of acute pan-creatitis, as this likely reflects multiple contributing pathogenic mechanisms. Patients with gallstone pancreatitis had disproportionately more visceral fat, alcohol had the least overall fat, and those without a clear cause had the lowest VFA/SFA ratio. Etiology is strongly associated with body fat distribution. Severity is associated with increased visceral fat, but much less so when etiology is controlled for. The radiological assessment of fat distribution thus can give clues to associated etiology.
... Due to the advantages of minimal invasion and low pain, difficult laparoscopic cholecystectomy (DLC) has gradually developed into the first choice for the surgical treatment of complex gallbladder diseases with the continuous development of laparoscopic cholecystectomy (LC) technology in the medical field in recent years [1,2]. LC was initially classified as either antegrade resection or retrograde resection. ...
Objective
To compare the effects of ampulla-guided realignment and conventional gallbladder triangle anatomy in difficult laparoscopic cholecystectomy (DLC).
Methods
From June 2021 to August 2022, data from 100 patients undergoing DLC at Nanjing Hospital of Traditional Chinese Medicine were analyzed retrospectively. Patients were divided into two groups: the experimental group (LC with the ampulla-guided realignment) and the control group (conventional LC with triangular gallbladder anatomy), with 50 patients per group. The intraoperative blood loss, operation time, postoperative drainage tube indwelling time, hospitalization time, bile duct injury rate, operation conversion rate, and incidence of postoperative complications were recorded and compared between the two groups. The pain response and daily activities of the patients in the two groups were evaluated 48 h after the operation.
Results
The amount of intraoperative blood loss, postoperative drainage tube indwelling time, hospital stay, operation conversion rate, pain degree at 24 and 48 h after operation, bile duct injury incidence, and total postoperative complication rate were shorter or lower in the experimental group than those in the control group (p < 0.05). The Barthel index scores of both groups were higher 48 h after the operation than before the operation, and the experimental group was higher than the control group (p < 0.05).
Conclusion
The ampulla-guided alignment in DLC surgery was more beneficial in promoting postoperative recovery, reducing postoperative pain response, reducing the incidence of postoperative complications, and reducing bile duct injury.
... A recent systematic review 22 reported a lower recurrence rate in 524 patients with IAP who underwent cholecystectomy versus non-surgical management from 10 studies (11.1 versus 35.2 per cent; risk ratio 0.44). However, EUS was not undertaken routinely in these patients. ...
Background
Cholecystectomy in patients with idiopathic acute pancreatitis (IAP) is controversial. A randomized trial found cholecystectomy to reduce the recurrence rate of IAP but did not include preoperative endoscopic ultrasonography (EUS). As EUS is effective in detecting gallstone disease, cholecystectomy may be indicated only in patients with gallstone disease. This study aimed to determine the diagnostic value of EUS in patients with IAP, and the rate of recurrent pancreatitis in patients in whom EUS could not determine the aetiology (EUS-negative IAP).
Methods
This prospective multicentre cohort study included patients with a first episode of IAP who underwent outpatient EUS. The primary outcome was detection of aetiology by EUS. Secondary outcomes included adverse events after EUS, recurrence of pancreatitis, and quality of life during 1-year follow-up.
Results
After screening 957 consecutive patients with acute pancreatitis from 24 centres, 105 patients with IAP were included and underwent EUS. In 34 patients (32 per cent), EUS detected an aetiology: (micro)lithiasis and biliary sludge (23.8 per cent), chronic pancreatitis (6.7 per cent), and neoplasms (2.9 per cent); 2 of the latter patients underwent pancreatoduodenectomy. During 1-year follow-up, the pancreatitis recurrence rate was 17 per cent (12 of 71) among patients with EUS-negative IAP versus 6 per cent (2 of 34) among those with positive EUS. Recurrent pancreatitis was associated with poorer quality of life.
Conclusion
EUS detected an aetiology in a one-third of patients with a first episode of IAP, requiring mostly cholecystectomy or pancreatoduodenectomy. The role of cholecystectomy in patients with EUS-negative IAP remains uncertain and warrants further study.
... [12] Today, although the role of cholecystectomy in preventing post-ABP biliary events and recurrent ABP attacks is undisputed, there are still some debates about the timing of gallbladder removal. [5,13] Early index cholecystectomies have been recommended in mild-attack ABP in recent years. However, in severe ABP, it is generally recommended to perform cholecystectomy at least 6 weeks after the onset of the attack. ...
Background:
The COVID-19 pandemic thoroughly changed the daily practices of medicine. We retrospectively evaluated the impact of the COVID-19 pandemic on our management strategies for patients with acute biliary pancreatitis (ABP).
Methods:
A total of 91 patients with ABP who were treated at Trakya University Faculty of Medicine between March 15, 2019 and March 15, 2021 were retrospectively recruited. Patients were classified as pre-COVID and COVID-era patients. The comorbidity markers, data from laboratory tests, inflammatory markers, and radiological examinations were evaluated. Length of stay, need for an intensive care unit, morbidity, mortality, recurrent ABP, and definitive treatment rates were evaluated, and the data of the two periods were compared.
Results:
Two groups of patients, 57 in the pre-COVID period and 34 in the COVID period, were included in the study. We found that ABP admissions decreased significantly during periods of increased national COVID-19 diagnoses. Type 2 diabetes mellitus was significantly higher in the COVID period patients (P=0.044), and COVID patients had significantly higher total (P=0.004), direct bili-rubin (P=0.007), and lipases (P<0.001). The cholecystectomy rate after an attack decreased from 26% in the pre-COVID period to 15.6% during COVID.
Conclusion:
COVID strikingly reduced the admissions of ABP patients in the early stages of the disease to hospitals, leading to inevitable admissions in advanced severity. Moreover, a significant increase was detected in the recurrence rates of ABP. This can be explained by the reduction in cholecystectomy performed.
... [12] Today, although the role of cholecystectomy in preventing post-ABP biliary events and recurrent ABP attacks is undisputed, there are still some debates about the timing of gallbladder removal. [5,13] Early index cholecystectomies have been recommended in mild-attack ABP in recent years. However, in severe ABP, it is generally recommended to perform cholecystectomy at least 6 weeks after the onset of the attack. ...
BACKGROUND: The COVID-19 pandemic thoroughly changed the daily practices of medicine. We retrospectively evaluated the impact of the COVID-19 pandemic on our management strategies for patients with acute biliary pancreatitis (ABP).
... At this point, a referral was made to a specialty pancreatitis center at an academic hospital per patient's wish. According to a recent systematic review and meta-analysis, the recurrence rate of pancreatitis is lower after cholecystectomy in patients with idiopathic acute pancreatitis [4]. However, in this case neither gallstone nor cholesterol polyp can cause irritation or obstruction of the pancreatic duct after the removal of the gallbladder with successful normal cholangiogram which was prompted by the possible sludge in MRCP. ...
Biliary pathologies are common causes of acute pancreatitis, including gallbladder cholesterolosis and gallstone pancreatitis. Nevertheless, after these two pathologies have been excluded, a broader differential and less common etiologies must be considered. Here we report an 18-year-old female with preliminary diagnosis of gallstone pancreatitis who underwent cholecystectomy and intraoperative cholangiogram resulting in uneventful recovery and resolution of symptoms. She returned three times within the month with symptoms of acute pancreatitis. We discussed alternative etiologies of her pancreatitis after exclusion of other causes with extensive imaging and laboratory evaluation.
... However, cholecystectomy for suspected microlithiasis and cholestasis has been shown to prevent subsequent attacks [26]. A meta-analysis [27] of 10 studies revealed that cholecystectomy is effective in reducing the risk of recurrence of idiopathic acute pancreatitis. The results of the present study showed that ERCP was effective in reducing UOs in patients with CBDM compared with those in the without ERCP group. ...
Background
Common bile duct microlithiasis (CBDM) with a diameter of ≤ 3 mm can pass spontaneously without causing any symptoms, but in some cases, it can also cause severe cholangitis and pancreatitis. The optimal strategy for managing CBDM is yet to be determined.
Methods
Data of 154 patients with CBDM were collected and divided into two groups: with endoscopic retrograde cholangiopancreatography (with ERCP, n = 82) and without ERCP (n = 72). Clinical outcomes, including the incidence of unfavorable outcomes (UOs), such as cholangitis and pancreatitis, were observed and compared between the two groups.
Results
The incidence of UOs was significantly lower in the ERCP group than in the without ERCP group (3.7% vs. 23.6%, respectively, p < 0.001). Moreover, the total number of readmissions was also lower in the ERCP group than in the without ERCP group (p < 0.001). A multivariate analysis adjusted for age, sex, and the American Society of Anesthesiologists (ASA) class revealed that endoscopic sphincterotomy (EST) and cholecystectomy were associated with a lower risk of UOs.
Conclusion
The high rate of UOs in CBDM patients without ERCP suggests that its natural clinical course may not be as favorable as previously suggested. This finding implies that efforts should be made to clear the bile ducts.
... Prasanth et al. 58 conducted a meta-analysis of 11 randomized controlled trials and concluded that early cholecystectomy has definite advantages in terms of reducing recurrent pancreaticobiliary events and length of hospital stay after gallstone pancreatitis. 58 A recent meta-analysis conducted by Umans et al. 59 showed that cholecystectomy after idiopathic acute pancreatitis may also reduce the risk of recurrent pancreatitis and argued that current diagnostics are insufficient to exclude a biliary cause in this setting. 59 The available data from the included studies in our review were not adequate to perform subgroup analyses for patients with idiopathic acute pancreatitis who underwent cholecystectomy; hence, we cannot make any conclusions against or in favor of the findings by Umans et al. 59 It was very interesting to see that the risk of recurrent pancreatitis after the first episode of pancreatitis did not significantly differ among patients with mild, moderate, and severe pancreatitis. ...
... 58 A recent meta-analysis conducted by Umans et al. 59 showed that cholecystectomy after idiopathic acute pancreatitis may also reduce the risk of recurrent pancreatitis and argued that current diagnostics are insufficient to exclude a biliary cause in this setting. 59 The available data from the included studies in our review were not adequate to perform subgroup analyses for patients with idiopathic acute pancreatitis who underwent cholecystectomy; hence, we cannot make any conclusions against or in favor of the findings by Umans et al. 59 It was very interesting to see that the risk of recurrent pancreatitis after the first episode of pancreatitis did not significantly differ among patients with mild, moderate, and severe pancreatitis. The available data were not adequate to investigate whether this finding remains consistent among the patients with different etiology of pancreatitis. ...
... 58 A recent meta-analysis conducted by Umans et al. 59 showed that cholecystectomy after idiopathic acute pancreatitis may also reduce the risk of recurrent pancreatitis and argued that current diagnostics are insufficient to exclude a biliary cause in this setting. 59 The available data from the included studies in our review were not adequate to perform subgroup analyses for patients with idiopathic acute pancreatitis who underwent cholecystectomy; hence, we cannot make any conclusions against or in favor of the findings by Umans et al. 59 It was very interesting to see that the risk of recurrent pancreatitis after the first episode of pancreatitis did not significantly differ among patients with mild, moderate, and severe pancreatitis. The available data were not adequate to investigate whether this finding remains consistent among the patients with different etiology of pancreatitis. ...
Background and aim:
The study aims to determine and quantify the stratified risk of recurrent pancreatitis (RP) after the first episode of acute pancreatitis in relation to etiology and severity of disease.
Methods:
A systematic review and meta-analysis in compliance with PRISMA statement standards was conducted. A search of electronic information sources was conducted to identify all studies investigating the risk of RP after the first episode of acute pancreatitis. Proportion meta-analysis models using random effects were constructed to calculate the weighted summary risks of RP. Meta-regression was performed to evaluate the effect of different variables on the pooled outcomes.
Results:
Analysis of 57,815 patients from 42 studies showed that the risk of RP after first episode was 19.8% (95% confidence interval [CI] 17.5-22.1%). The risk of RP was 11.9% (10.2-13.5%) after gallstone pancreatitis, 28.7% (23.5-33.9%) after alcohol-induced pancreatitis, 30.3% (15.5-45.0%) after hyperlipidemia-induced pancreatitis, 38.1% (28.9-47.3%) after autoimmune pancreatitis, 15.1% (11.6-18.6%) after idiopathic pancreatitis, 22.0% (16.9-27.1%) after mild pancreatitis, 23.9% (12.9-34.8%) after moderate pancreatitis, 21.6% (14.6-28.7%) after severe pancreatitis, and 6.6% (4.1-9.2%) after cholecystectomy following gallstone pancreatitis. Meta-regression confirmed that the results were not affected by the year of study (P = 0.541), sample size (P = 0.064), length of follow-up (P = 0.348), and age of patients (P = 0.138) in the included studies.
Conclusions:
The risk of RP after the first episode of acute pancreatitis seems to be affected by the etiology of pancreatitis but not the severity of disease. The risks seem to be higher in patients with autoimmune pancreatitis, hyperlipidemia-induced pancreatitis, and alcohol-induced pancreatitis and lower in patients with gallstone pancreatitis and idiopathic pancreatitis.
... For example, a 2015 randomized control trial demonstrated a reduction in the recurrence rate from 30.5% without intervention to 10.3% after LC [12]. This trial was included in a meta-analysis of 524 patients demonstrating a reduction in recurrence from 35.2% to 11.1% following cholecystectomy [15]. The utility of ES in IAP was first studied in a 1992 trial involving 19 patients that demonstrated a reduction in recurrence for patients with IAP, and it is an option listed by multiple pancreatic societies for patients with IAP [7,[16][17][18]. ...
... The likelihood of receiving a correct workup or a specific intervention were compared between patients based on demographics, socioeconomic factors, increasing BMI or a diagnosis date before or after 2020. The largest meta-analysis supporting LC in IAP was published in 2020, which may have altered general approaches to the disease, prompting the date cut-off of 2020 [15]. ...
... As a diagnosis of exclusion, the condition requires a complete work-up, and previous studies have shown that a large proportion of patients do not receive a thorough work-up, and uncomplicated cases provide the opportunity for under-diagnosis. For example, a large 2020 meta-analysis found that only a quarter of patients diagnosed with IAP had a complete work-up to truly make that diagnosis [15]. Our study also found a very low percentage of patients (28.9%) with potentially idiopathic pancreatitis after their workup, and only 4 % of patients received either MRCP or EUS, the two modalities of advanced imaging recommended for this condition [5]. ...
Introduction:
Idiopathic acute pancreatitis (IAP) is a diagnosis of exclusion; systematic work-up is challenging but essential. Recent advances suggest IAP results from micro-choledocholithiasis, and that laparoscopic cholecystectomy (LC) or endoscopic sphincterotomy (ES) may prevent recurrence.
Methods:
Patients diagnosed with IAP from 2015-21 were identified from discharge billing records. Acute pancreatitis was defined by the 2012 Atlanta classification. Complete workup was defined per Dutch and Japanese guidelines.
Results:
A total of 1499 patients were diagnosed with IAP; 455 screened positive for pancreatitis. Most (N = 256, 56.2%) were screened for hypertriglyceridemia, 182 (40.0%) for IgG-4, and 18 (4.0%) MRCP or EUS, leaving 434 (29.0%) patients with potentially idiopathic pancreatitis. Only 61 (14.0%) received LC and 16 (3.7%) ES. Overall, 40% (N = 172) had recurrent pancreatitis versus 46% (N = 28/61) following LC and 19% (N = 3/16) following ES. Forty-three percent had stones on pathology after LC; none developed recurrence.
Conclusion:
Complete workup for IAP is necessary but was performed in <5% of cases. Patients who potentially had IAP and received LC were definitively treated 60% of the time. The high rate of stones on pathology further supports empiric LC in this population. A systematic approach to IAP is lacking. Interventions aimed at biliary-lithiasis to prevent recurrent IAP have merit.
... ERCP and sphincterotomy alone can halve the risk of recurrent pancreatitis in those unfit for surgery, but does not reduce the risk to the same extent as cholecystectomy [141], and increases the risk of subsequent cholecystitis from compromise of sphincter of Oddi function. If extensive investigation for aetiology is negative, resulting in an idiopathic diagnosis, cholecystectomy may still be justified; recurrence after cholecystectomy in idiopathic acute pancreatitis is lower than with conservative management [218]. After a first attack of acute pancreatitis, at least 20% of patients have a recurrence, approaching half of whom subsequently develop chronic pancreatitis, notably in males who continue to smoke and/or consume alcohol [219]. ...
Acute pancreatitis is a common indication for hospital admission, increasing in incidence, including in children, pregnancy and the elderly. Moderately severe acute pancreatitis with fluid and/or necrotic collections causes substantial morbidity, and severe disease with persistent organ failure causes significant mortality. The diagnosis requires two of upper abdominal pain, amylase/lipase ≥ 3 ×upper limit of normal, and/or cross-sectional imaging findings. Gallstones and ethanol predominate while hypertriglyceridaemia and drugs are notable among many causes. Serum triglycerides, full blood count, renal and liver function tests, glucose, calcium, transabdominal ultrasound, and chest imaging are indicated, with abdominal cross-sectional imaging if there is diagnostic uncertainty. Subsequent imaging is undertaken to detect complications, for example, if C-reactive protein exceeds 150 mg/L, or rarer aetiologies. Pancreatic intracellular calcium overload, mitochondrial impairment, and inflammatory responses are critical in pathogenesis, targeted in current treatment trials, which are crucially important as there is no internationally licenced drug to treat acute pancreatitis and prevent complications. Initial priorities are intravenous fluid resuscitation, analgesia, and enteral nutrition, and when necessary, critical care and organ support, parenteral nutrition, antibiotics, pancreatic exocrine and endocrine replacement therapy; all may have adverse effects. Patients with local complications should be referred to specialist tertiary centres to guide further management, which may include drainage and/or necrosectomy. The impact of acute pancreatitis can be devastating, so prevention or reduction of the risk of recurrence and progression to chronic pancreatitis with an increased risk of pancreas cancer requires proactive management that should be long term for some patients.
