Almonds Chocolate - Almond Board of California

12 Pages·2008·0.36 MB·English

3/28/2012
Gallstone Pancreatitis:
Gallstone Pancreatitis:
Introduction
An Evidence-Based Approach
(cid:1) Literature is difficult to interpret because of
large series with heterogeneous populations
Stanley Rogers, MD
Associate Clinical Professor of Surgery (cid:1) Examine the evidence to address specific
Ruth M. Dunn Chair and Chief,
questions commonly encountered in a
Minimally Invasive Surgery
general surgical practice.
Director, Bariatric Surgery
University of California, San Francisco
UCSF Post Graduate Course in General Surgery
Tuesday, March 27, 2012
Gallstone Pancreatitis:
Epidemiology
Questions
(cid:1) Incidence
1. What is the incidence of finding CBDS in GSP?
(cid:1) Acute pancreatitis 4.8 - 73.4 cases per
2. Can the course of acute GSP be altered by treating
CBDS? 100,000 / year
3. What is the best timing for LC as definitive (cid:1)Scotland: 24 cases per 100,000
treatment after resolution of GSP?
(cid:1)Finland: 73 cases per 100,000
4. In resolving, uncomplicated pancreatitis, what is the
appropriate way to detect and manage potential (cid:1) Gallstone pancreatitis: 35-57% of all cases
CBDS? (cid:1) Mortality
(cid:1) Overall for hospitalized pts with severe acute
pancreatitis: 10%
1
3/28/2012
GS Pancreatitis: GS Pancreatitis:
Pathogenesis CBDS Pathogenesis
(cid:1) Eugene Opie, 1901:
(cid:1)Mechanism for pancreatitis is the gallstone (cid:1) Juan Miguel Acosta, 1974
(cid:1)Post-mortem dissection of bile ducts in pancreatitis (cid:1) Stool screened for gallstones within the first 10 days of
pts – presentation (done by surgical house staff!)
(cid:1)found a GS impacted in the ampulla of Vater in a pt 36 pts with GBS and acute pancreatitis (AP) vs.
who died of pancreatitis –now recognized that this is 36 pts with GBS but no pancreatitis
an extremely rare occurrence
(cid:1)“Common channel bile reflux theory” (cid:1) GBS withAP: 34/36(94.4%) had GS in stool
(cid:1)Opie E. Johns Hopkins Hosp Bull 1901; 121: 182 (cid:1) GBS withoutAP: 3/36(8.3%) had GS in stool
(cid:1) Found gallstones in 94% within the first 10 days of
TThhee ccaauussaall rreellaattiioonnsshhiipp ffeellll iinnttoo qquueessttiioonn wwhheenn
presentation
ssttoonneess iinn tthhee CCBBDD wweerree ffrreeqquueennttllyy NNOOTT ffoouunndd..
Acosta J, Ledesma C. N Engl J Med1974; 290: 484
CBD Incidence in Gallstone Pancreatitis
Gallstone Pancreatitis
CBDS Predictors
(cid:1) Kelly 1976 (cid:1) Abboud et al 1999
(cid:1) Again, screening stool for stones….
(cid:1) Presence of GS in stool of pts with GSP was (cid:1) Metaanalysis
significantly more common than in pts with other (cid:1)LR of CBD Stone with history of recent
forms of biliary symptoms.
pancreatitis is 2.1
(cid:1)LR of CBD stone with history of
(cid:1) Stones tended to appear in stool specimens as
hyperamylasemia is 1.5
symptoms improved, suggesting that passageof
the stone correlates with clinical improvement
2
3/28/2012
CBD Incidence in Gallstone Pancreatitis Gallstone Pancreatitis
Summary Treatment Options: Medical
(cid:1) General conservative treatment: Bowel rest
(cid:1) Gallstones cause pancreatitis
(NPO status), IVF, narcotic meds
(cid:1) Stones frequently pass spontaneously
(cid:1) ±NGT suction - 4 prospective randomized trials
(cid:1) Incidence of identifying calculi in the CBD
showed no difference in outcome compared to
decreases with time from onset of symptoms
(cid:1) Clearance of stones from CBD (& subsequent no NGT – only use if ileus.
finding in stool) correlates with relief of symptoms & (cid:1) Levant. JAMA1974; 229:51
resolution of GSP (cid:1) Loiudice. Am J Gastroenterol1984; 79:53
(cid:1) Naeije. Br Med J1978; 2: 659
(cid:1) Sarr. Surgery1986; 100: 500
Gallstone Pancreatitis Gallstone Pancreatitis
Treatment Options: Medical Treatment Options: Medical
(cid:1) Platelet activating factor inhibitors (Lexipafant) –
(cid:1) No benefit from atropine or glucagon
no benefit
(cid:1) H2 receptor antagonist or PPI -no benefit (cid:1) Protease inhibitors
(cid:1) Broe. Surg Gynecol Obstet1982; 154: 13 (cid:1) Aprotinin-no benefit
(cid:1) Loiudice. Am J Gastroenterol1984; 79:53 (cid:1) Imrie. Br J Surg1975; 65: 337
(cid:1) Somatostatin & Octreotide-no benefit (but does have (cid:1) MRC Multicenter Trial. Gut1980; 21: 334
a role in fistulae) (cid:1) Gabexatemesylate- no benefit
(cid:1) Choi. Gut1989; 30: 223 (cid:1) Buchler. Gastroenterology1993; 104: 1165
(cid:1) D’amico. Hepatol Gastroenterol1990; 37: 92 (cid:1) Valderama. Digestion1992; 51: 65
(cid:1) Gjorup. Surg Gynecol Obstet1992; 175: 397 (cid:1) FFP-no benefit
(cid:1) Usadel. Dig Dis Sci1985; 30: 992
(cid:1) Leese. Br J Surg1987; 74: 907
(cid:1) Lesse. Ann R CollSurgEngl1991: 73: 207
3
3/28/2012
Gallstone Pancreatitis Gallstone Pancreatitis
Treatment Options: Medical Treatment Options: Medical
(cid:1) Total EnteralNutrition (TEN)
(cid:1) TPN
Enteral feeds should be post ligament of
(cid:1) In mild pancreatitis -no benefit
Treitz (not gastric or duodenal feeding…)
(cid:1)Sax. Am J Surg1987; 153: 117
→ GIP / VIP / somatostatin stimulation
→ suppresses pancreatic activity
(cid:1) In severe pancreatitis -showed benefit
while giving nutritional benefit
(cid:1)Kalfarentzos. J Am Coll Nutr1991; 10: 156 (cid:1) Advantages:
(cid:1)reduced complications (24% vs 96%) (cid:1) reduced cost compared to TPN or PPN
(cid:1)reduced mortality (13% vs 38%) (cid:1) no associated risk of catheter line sepsis
(cid:1) prevents gut atrophy and bacterial translocation and infection
(cid:1) Disadvantages:
(cid:1) risk of proximal migration of the tube tip into the duodenum or
stomach
(cid:1) patient refusal due to discomfort
Gallstone Pancreatitis
Prophylactic Antibiotics
(cid:1) Pederzoli. Surg Gynecol Obstet 1993; 176: 480
(cid:1) Does removing CBD calculi provide
(cid:1) Imipenem n=41 vs no antibiotic n=33
benefit for acute GSP with
(cid:1) Significant reduction in pancreatic infection
(cid:1)12% vs 30% improvement in course / resolution of
(cid:1) No change in mortality inflammation?
(cid:1) Sainio. Lancet 1995; 346: 663
(cid:1) Luiten. Ann Surg 1995; 222: 57
(cid:1) Bassi. Gastroenterology1998; 115: 1513
(cid:1) Overall: consider for use in severe pancreatitis!
4
3/28/2012
Gallstone Pancreatitis Gallstone Pancreatitis
CBDS treatment – open surgery CBDS treatment?
Kelly 1982 (cid:1) Kelly et al
(cid:1) Pre-ERCP Era – open surgery (cid:1) Randomized controlled trial
(cid:1) Early treatment (<48h) had a higher mortality
(cid:1) Ranson’s score > 3: higher mortality if
rate than late treatment (where incidence of
submitted to pancreatic surgery early in the
CBD stones less)
clinical course - prior to resolution of
pancreatitis
Risk of laparotomy outweighed the benefit of
removing the CBD stone.
(cid:1) In the ERCP Era, the issue was revisited
because of the perceived lower risk of the
procedure.
Gallstone Pancreatitis Gallstone Pancreatitis
Severity of Disease CBD Stones
(cid:1) Neoptolomos et al (cid:1) Fan et al.
(cid:1) Statistically significant decrease in LOS for patients with
(cid:1)Also found a non-significant trend of decreased
severe pancreatitis only who were offered urgent
ERCP+ES, if a stone was found and removed. mortalityin severe pancreatitis for patients who
had urgent intervention.
(cid:1) Trend for lower incidence of complications and mortality in
the severegroup who underwent urgent intervention.
(cid:1)When gallstone pancreatitis subgroup is
(cid:1)When the patients with a biliary tract indication analyzed, the only benefit is seen in patients
for ERCP are removed, there is no significant with a biliary tract indication for ERCP
difference between early and late treatment.
(cid:1) Also demonstrated that there is no increased risk of
complications from the ERCP itself.
5
3/28/2012
Gallstone Pancreatitis Gallstone Pancreatitis
CBD Stones CBD Stones
(cid:1) Folsch et al (cid:1) Acosta and Pelligrini
(cid:1) 238 Patients with no biliary obstruction randomizedto (cid:1) JACS, August 1997
early ERCP (126) or later ERCP if biliary symptoms (cid:1) Experimental and clinical evidence that
presented (112)
(cid:1) 58 patients in early group had a stone present, which was duration of stone impactioncorrelates with the
removed severity of pancreatitis.
(cid:1) 22 patients in observation group developed a biliary (cid:1) Major complications of pancreatitis were rare if
indication for ERCP (cid:2)13 had CBD stone
the stone passed in <48 hours
(cid:1) Early group had more respiratory failure (p<0.03)
(cid:1) Overall mortality within three months was 11% in the early
group, 6% in the observation group (NSS)
(cid:1) A policy of early ERCP / ES does not benefit patients with
acute pancreatitis without biliary indication.
(cid:1) Did not stratify mild vs. severe pancreatitis
Gallstone Pancreatitis Gallstone Pancreatitis
CBD Stones CBD Stone Treatment
(cid:1) Borie et al (cid:1) The literature is confusing because of heterogeneous
(cid:1) Systematic review populations with differing indications for ERCP
(cid:1) Surgical Endoscopy Aug 2003
(cid:1) When biliary indications are excluded, the (cid:1) Without concern for CBDS, there is NO proof the early
complication rates are no different with or without ERCP/ES improves the course of pancreatitis in a
ERCP stable patient
(cid:1) There is no evidence to support ES in severe
pancreatitis if calculi are not present (cid:1) Probable benefit in pts with severe pancreatitis who
are deteriorating
6
3/28/2012
Gallstone Pancreatitis Gallstone Pancreatitis
IOC during LC IOC during LC
(cid:1) No studies relating to patients with pancreatitis (cid:1) Mills et al.
alone. (cid:1) Review of 8 series
(cid:1) Average incidence of CBDS = 2.5%
(cid:1) Mickley and Reisman (cid:1) In pts without IOC, 0.03 to 0.8% will present
(cid:1) In patients with known or clinically later with symptomatic stones
suspected CBD stones, clinical symptoms
develop in 100% patients in 5 years. (cid:1) Rec: always to investigate (IOC) and treat potential
CBD stones in GSP patients as early as possible
following resolution of pancreatitis.
Gallstone Pancreatitis
Gallstone Pancreatitis
Managing Potential CBD Stones
(cid:1) There are no studies specific to the
(cid:1) In resolving, uncomplicated pancreatitis, gallstone pancreatitis population
what is the most appropriate management (cid:1) Extrapolate from the general CBD stone
of suspected CBD stones? literature
(cid:1) Debate: pre-op ERCP vs. planned IOC,
and intraop or postop stone removal by
various methods
7
3/28/2012
Gallstone Pancreatitis Gallstone Pancreatitis
Managing Potential CBD Stones Managing Potential CBD Stones
(cid:1) Laparoscopic Era Evidence
(cid:1) Open Surgery Era Evidence
(cid:1) Sees et al
(cid:1) Voluminousliterature
(cid:1) LC/OCBDE shorter LOS than preop ERCP/LC (cid:2)
ERCP pancreatitis
(cid:1) Four randomized trials (cid:1) Cuschieri et al
(cid:1) All favoured one stage OC/IOC/OCBDE over pre op (cid:1) European Collaborative Trial
ERCP and OC (cid:1) LC/IOC +/-LCBDE superior to pre op ERCP/LC
(cid:1) Neoptolemosand Carr-Locke (cid:1) Also Rhodes et al., Sqourakis et al.
(cid:1)55 preopERCP = 3.6% mortality
(cid:1)59 one stage surgery = 1.7% mortality
Gallstone Pancreatitis GSP: Managing Potential CBDS
Managing Potential CBD Stones
(cid:1) Laparoscopic Era Evidence
(cid:1) Tse, Barkun et al
(cid:1) Decision analysis model
(cid:1) High risk= Pre op ERCP
(cid:1) Criteria: (>80% likelihood CBD stone)
(cid:1) Medium risk (includes history of pancreatitis)=
LC/IOC;
(cid:1) Stone removal if identified (via LCBDE, post op ERCP or
OCBDE)
(cid:1) Low risk= no imaging of duct
(cid:1) Also: Urbach et al (2001)
8
3/28/2012
GSP: Managing Potential CBDS GSP: Managing Potential CBDS
(cid:1) No evidence to support pre-operative ERCP in GSP
patients awaiting LC
Instead:
(cid:1) Showed that ERCP/S +LC and LC +LCBDE were both:
(cid:1) highly effective in detecting and removing common bile duct (cid:1) IOC should be done in all GSP patients during LC
stonesand
(cid:1) equivalent in overall cost and patient acceptance.
(cid:1) Decision for LCBDE or post op ERCP (or OCBDE)
(cid:1) Overall duration of hospitalization was shorter for LC+LCBDE. should be made depending on findings and on local
expertise
(cid:1) A single surgical procedure for common bile duct stone disease is
feasible, cost-effective, and ultimately should be made available for
most patients. (cid:1) General surgeons should learn LCBDE to offer
patients optimal care.
Timing for LC after GSP Timing of LC after GSP
(cid:1) Osbourne / Tandelli
(cid:1) What is the best timing for LC as definitive (cid:1) BJS, ~1960
(cid:1) Recommended OC prior to hospital discharge
treatment after an episode of gallstone
because early risk of recurrent pancreatitis
pancreatitis?
(cid:1) Kelly 1988
(cid:1) RCT OC <= 3 days after onset vs. >= 3 days but
before discharge
(cid:1)Higher mortality (3.3 vs. 0%) and morbidity (48
vs. 11.3%) with early surgery
9
3/28/2012
Best Timing for LC after GSP Best Timing for LC after GSP
(cid:1) Uhl et al. (cid:1) Barkun et al. 1994
(cid:1) 35 patientspre-laparoscopic era
(cid:1) Surgical Endoscopy 1999
(cid:1)Average time to surgery (OC) 9.9 days
(cid:1) Reviewed 5 case series:
(cid:1)Complications while waiting for surgery = 0
(cid:1)Recurrent pancreatitis in 29 – 63% if (cid:1) 58 patients-early laparoscopic era –wait for surgery
discharged without cholecystectomy (cid:1)Average time to surgery (LC) 39.3 days
(cid:1)Complications while waiting:
(cid:1) 1x cholangitis
(cid:1) 2x acute cholecystitis
(cid:1) 3x recurrent pancreatitis
(cid:1) Recommended LC during index hospitalization, as early
as possible after stabilization and resolution of GSP
Gallstone Pancreatitis Best Timing for LC after GSP
Surgery: Risk of Conversion
(cid:1) Pelligrini
(cid:1) Borie et al.
(cid:1) AJS (vol 165) -- 1994
(cid:1) Review of 5 LC case series
(cid:1) NIH Consensus conference
(cid:1) Early operation and >3 Ranson’s criteria
(cid:1) Optimum time 5-6 days following onset of
were associated with increased conversion
pancreatitis
rate
10