Early Versus Delayed Surgery for Gallstone Pancreatitis
Early Versus Delayed Surgery for Gallstone Pancreatitis
While there exists consensus among surgeons that patients with gallstone pancreatitis should
 undergo cholecystectomy to prevent recurrence, the precise timing of laparoscopic
 cholecystectomy for mild to moderate disease remains controversial. We hypothesize that
 laparoscopic cholecystectomy performed within 48 hours of admission, regardless of resolution
 of abdominal pain or abnormal laboratory values, will result in a shorter hospital stay.
Acute pancreatitis is a common diagnosis worldwide, with more than 220,000 cases reported
 annually in the United States alone. The leading etiology is gallstones.1 Gallstone
 pancreatitis is thought to occur due to transient obstruction of the common channel that
 drains both the biliary and pancreatic ducts, resulting in inflammation of the pancreas. The
 pancreatitis that ensues is usually mild and self-limited and the treatment is initially
 supportive with subsequent laparoscopic cholecystectomy (LC). However, a small subgroup of
 patients develop severe pancreatitis and/or concomitant cholangitis. When the latter is
 present, ERC and sphincterotomy with stone extraction as indicated are typically performed.

 While there is a clear consensus that patients who present with gallstone pancreatitis should
 undergo cholecystectomy to prevent recurrence, precise timing of surgery remains
 controversial. In patients with severe pancreatitis (Ranson's > 3), there is consensus that
 surgery is delayed until the pancreatitis has resolved because early operation is associated
 with a higher complication rate. 2 However, despite more than 30 years of debate in the
 surgical literature, the optimal timing of surgery in mild to moderate pancreatitis (Ranson's
 ≤ 3) remains unclear. With recurrence rates for gallstone pancreatitis reported as high as
 63%3 and with some of the repeat attacks occurring within two weeks of initial index
 presentation1, most investigators have recommended cholecystectomy during the initial
 hospitalization.4,5 Still, the actual timing of surgery during the initial index
 hospitalization is unsettled. In practice, surgeons often delay surgery until there is
 evidence of complete resolution of the inflammatory process, as evidenced by absence of
 abdominal pain and normalization of liver functional tests and pancreatic enzymes.6
 Unfortunately, this strategy may result in prolongation of hospitalization without any proven
 benefit.

 A previous prospective, non-randomized study from our institution suggested that early
 cholecystectomy could safely be performed within 48 hours of admission in patients with mild
 to moderate pancreatitis, regardless of resolution of abdominal pain and abnormal laboratory
 values. In this study, when compared to a retrospective control group in which surgery was
 delayed until there was resolution of clinical and laboratory parameters, hospital stay was
 significantly reduced from a median of 7 days to 4 days, without additional complications.7
 In order to address the optimal timing of surgery in a more definite fashion, a prospective
 randomized study was performed in which patients with mild to moderate gallstone pancreatitis
 were allocated to either an early group (surgery within 48 hours of presentation) or a
 control group (surgery after resolution of abdominal pain and normalization of laboratory
 values) and assessed overall outcomes.
Inclusion Criteria:

 -  All adults are included between the age of 18 and 100 with mild to moderate gallstone
 pancreatitis.

 -  A subject is classified as having gallstone pancreatitis if they had the following:

 1. upper abdominal pain, nausea, vomiting and epigastric tenderness;

 2. absence of ethanol abuse;

 3. elevated amylase level to at least twice the upper limit of normal and elevated
 lipase level to at lease three times the upper limit of normal; and

 4. imaging confirmation of gallstones.

 -  The classification of mild to moderate pancreatitis is defined by the presence of the
 following:

 1. three or fewer Ranson's criteria on admission: age > 55 years, glucose > 200
 mg/dL , LDH> 350 mg/dL, AST > 250 units/L, and WBC>16 K/mm3;

 2. clinical stability with admission to a non-monitored ward bed;

 3. absence of acute cholangitis: defined as a temperature >38.6°C, right upper
 quadrant pain and tenderness, and significant hyperbilirubinemia; and

 4. low suspicion for a retained common bile duct (CBD) stone (total bilirubin <4
 mg/dl on admission).

 Exclusion Criteria:

 -  Severe pancreatitis (as defined by the presence of more than three Ranson's criteria
 on admission);

 -  Suspected concomitant acute cholangitis;

 -  High suspicion for retained common bile duct stone (total bilirubin ≥ 4 mg/dl on
 admission or ultrasound demonstration of CBD stone);

 -  Patient refusal to participate;

 -  Severe preexisting medical comorbidities contraindicating cholecystectomy (as
 determined by the primary physicians);

 -  Pregnancy,

 -  Prior gastric bypass surgery (making ERC difficult )

 -  Admission to a monitored unit. The need for admission to a monitored bed is determined
 by the admitting surgeon and is guided primarily by a need for aggressive fluid
 administration as demonstrated by severe volume depletion (e.g., admission tachycardia
 >110 beats/minute, blood urea nitrogen > 15 mg/dl) or evidence of cholangitis.