Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice (42 page)
Read Core Topics in General & Emergency Surgery: Companion to Specialist Surgical Practice Online
Authors: Simon Paterson-Brown MBBS MPhil MS FRCS
In 1988, before laparoscopic surgery, Kelly and Wagner
111
randomised 165 patients with gallstone-induced acute pancreatitis to either early (
n
= 83) or late (
n
= 82) biliary surgery, with early surgery being undertaken within 48 hours of admission. In those with mild acute pancreatitis (
n
= 125) there was no significant difference in outcome between the two groups (morbidity: early 6.7% vs. late 3.3%,
P
> 0.10; mortality: early 3.1% vs. late 0%,
P >
0.10). However, in those with severe acute pancreatitis (
n
= 40) early biliary surgery resulted in a significant increase in morbidity and mortality (morbidity: early 82.6% vs. late 17.6%,
P
< 0.001; mortality: early 47.8% vs. late 11%,
P
< 0.025). A recent prospective study
112
randomised 50 patients with mild gallstone pancreatitis to laparoscopic cholecystectomy performed within 48 hours of admission, regardless of the resolution of abdominal pain or serum biochemistry, or performed once pain had resolved and biochemistry was normalising. The primary end-point, hospital length of stay, was significantly shorter in the early surgery group, with no apparent impact on the technical difficulty of the procedure or perioperative complication rate. However, careful patient selection for such early surgery remains important as other considerations may influence decision-making, such as further investigation and/or treatment of abnormal LFTs, persistent fever and so on, which may complicate assessment of the patient after laparoscopic cholecystectomy. As a result most surgeons still prefer to wait a few days until the acute attack has resolved before proceeding (still during the same hospital admission) with removal of the gallbladder.
British Society of Gastroenterology guidelines recommend that patients with gallstone-induced mild acute pancreatitis should undergo cholecystectomy (laparoscopic) during the same hospital admission unless a clear plan for definitive treatment within the following 2 weeks has been made.
51
In patients with severe comorbid disease contraindicating cholecystectomy, definitive treatment may be provided by ERCP and ES. In those with gallstone-induced severe disease, cholecystectomy should be delayed until disease resolution or undertaken as an additional procedure during surgery for a complication of the acute pancreatitis.
Infected necrosis
Many patients with pancreatic necrosis require minimal if any local intervention.
113
In those patients requiring intervention, an individualised approach is required. The interventional approaches to infected necrosis can be viewed as lying along a spectrum of ‘invasiveness’. The optimal therapeutic approach will depend on the patient's condition and the morphology and extent of the pancreatic or peripancreatic necrosis. Many patients with infected necrosis can be managed with radiologically guided percutaneous drainage alone. Minimally invasive necrosectomy techniques, e.g. minimally invasive retroperitoneal pancreatic necrosectomy (MIRP) and videoscopic-assisted retroperitoneal debridement (VARD), as well as radiologically guided limited incision open necrosectomy, have gained popularity and may result in lesser physiological insult than more traditional open necrosectomy. These patients should be managed within a specialist pancreatic unit where appropriate repertoire of interventional techniques is available.
Advances in imaging and endovascular intervention capabilities have increased the options available for patients that develop acute bleeding in association with pancreatic necrosis, often the result of pseudoaneurysm or true aneurysm formation. CT angiography is generally the preferred initial modality to localise the site of haemorrhage. Once the bleeding vessel is localised, directed transarterial embolisation can be attempted and, in many cases, obviates the need for a technically challenging laparotomy in an unwell patient with a ‘hostile abdomen’.
ERCP-related complications
The most common complications of ERCP and ES are pancreatitis, cholangitis, haemorrhage and duodenal perforation. Pancreatitis is managed in the same way as pancreatitis of any other aetiology. Cholangitis will commonly respond to antibiotic treatment, provided biliary drainage has been achieved at ERCP, either by effective stent placement or by clearing the biliary tree. Haemostasis can frequently be achieved endoscopically using local adrenaline injection into the papilla. However, should endoscopic haemostasis be ineffective, an operative approach may be required, particularly in a haemodynamically unstable patient. Generally, haemostasis can be achieved at laparotomy via a duodenotomy. Localisation of the ampulla, placement of the duodenotomy and initial tamponade can be facilitated by insertion of a Fogarty catheter via the cystic duct, through the ampulla. Definitive haemostasis can then achieved by direct suture similar to that carried out during a surgical ‘sphincteroplasty’. Care should be taken to avoid suturing the pancreatic duct and the use of a small cannula or probe can be helpful here.
Perforation may be apparent at the time of ERCP, but should be suspected in patients who develop severe pain or systemic physiological compromise following ERCP. CT is the preferred modality for diagnosis of perforation as the perforation is frequently retroperitoneal (
Fig. 8.12
). Small perforations may seal spontaneously and can, in some cases, be managed non-operatively by placing the patient nil by mouth, then initiating nasogastric tube drainage and systemic antibiotic treatment. The patient's nutritional status also requires careful attention. Should sepsis develop, a collection should be suspected and actively sought. Percutaneous drainage of the retroperitoneum may be required, although operative debridement should not be delayed if the patient's condition is not improved by percutaneous drainage, or if this approach is ineffective in controlling the collection. Again, referral to a specialist unit may be advisable as these complications can be difficult to treat and have a significant mortality.
Figure 8.12
CT image demonstrates retroperitoneal gas in a patient with iatrogenic perforation at ERCP.
This potentially life-threatening complication is fortunately relatively uncommon but may present to the non-pancreatic surgeon. A ‘herald bleed’ may precede major haemorrhage and in most cases following pancreaticoduodenectomy, the bleeding arises from the gastroduodenal artery stump. In patients sufficiently stable for transfer to radiology, CT angiography and endovascular treatment with embolisation may be sufficient to control haemorrhage. In patients requiring emergency laparotomy, mortality rates are significant.
Key points
Laparoscopic cholecystectomy is the gold standard intervention for the management of biliary colic and acute cholecystitis. Laparoscopic cholecystectomy during the index admission is both feasible and safe in patients with acute cholecystitis.
Percutaneous cholecystostomy may be undertaken in those patients with acute cholecystitis who do not respond to conservative management and who have significant comorbidity contraindicating emergency surgical intervention. Percutaneous cholecystostomy may be the definitive therapy in patients with acute acalculous cholecystitis.
Intravenous antibiotics and endoscopic drainage of the biliary tree form the basis of management for patients with acute cholangitis. Definitive management of acute cholangitis secondary to choledocholithiasis includes cholecystectomy in order to reduce the risk of further gallstone-related complications.
Acute pancreatitis is an increasingly common life-threatening illness. Initial management of severe acute pancreatitis involves appropriate resuscitation and organ support.
Routine administration of prophylactic antibiotics to all patients with predicted severe acute pancreatitis is not indicated, but should be considered in those patients with evidence of pancreatic necrosis who appear septic.
Early ERCP and ES should be undertaken in patients with gallstone-induced severe acute pancreatitis and evidence of either acute cholangitis or significant biliary obstruction (serum bilirubin > 90 μmol/L).
Surgery has little role in the initial management of severe acute pancreatitis.
Cholecystectomy should be undertaken in all patients with gallstone-induced acute pancreatitis during the index admission or within the next 2 weeks unless they have ongoing problems from severe disease or are unfit for surgery. In those unfit for surgery ERCP and ES should be considered as definitive treatment.
Complicated severe acute pancreatitis should be managed in a specialist unit.
1.
Birkmeyer, J.D., et al, Hospital volume and surgical mortality in the United States.
N Engl J Med
2002;346:1128–1137.
11948273
2.
Varghese, J.C., Farrell, M.A., Courtney, G., et al, A prospective comparison of magnetic resonance cholangiopancreatography with endoscopic retrograde cholangiopancreatography in the evaluation of patients with suspected biliary tract disease.
Clin Radiol
1999;54:513–520.
10484218
3.
Williams, E., Green, J., Guidelines on the management of common bile duct stones (CBDS).
Gut
2008;57:1004–1021.
18321943
4.
Tranter, S.E., Thompson, M.H., Comparison of endoscopic sphincterotomy and laparoscopic exploration of the common bile duct.
Br J Surg
2002;89:1495–1504.
12445057
Systematic review illustrating that laparoscopic exploration of the common bile duct may be a better way of removing stones than endoscopic sphincterotomy with laparoscopic cholecystectomy.
5.
Martin, D.J., Vernon, D.R., Toouli, J., Surgical versus endoscopic treatment of bile duct stones, Cochrane Database Syst Rev. 2006. [CD003327].
No clear difference was found in primary success rates, morbidity or mortality between the two approaches in the above two studies.
6.
Lo, C.M., Liu, C.L., Fan, S.T., et al, Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.
Ann Surg
1998;227:461–467.
9563529
A randomised study of 99 patients to either early (within 72 hours) or delayed laparoscopic cholecystectomy. Early surgery was associated with a lower conversion rate (early 11% vs. delayed 23%;
P
= 0.174), lower complication rate (early 13% vs. delayed 29%;
P
= 0.07), shorter total hospital stay (early 6 days vs. delayed 11 days;
P
< 0.001) and shorter recuperation period (early 12 days vs. delayed 19 days;
P
< 0.001).
7.
Lai, P.B., Kwong, K.H., Leung, K.L., et al, Randomized trial of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.
Br J Surg
1998;85:764–767.
9667702
A randomised study of 104 patients to either early (
n
= 53) or delayed (
n
= 51) laparoscopic cholecystectomy. Surgery would appear to have been more difficult in the early group as manifested by significantly longer operating times (123 vs. 107 min;
P
= 0.04); however, this did not translate into a higher conversion rate (early 21% vs. delayed 24%;
P
= 0.74). Morbidity rates were similar between the two groups, with no bile duct injuries reported. Early surgery was associated with a significant reduction in overall hospital stay (7.6 vs. 11.6 days;
P
< 0.001).
8.
Johansson, M., Thune, A., Blomqvist, A., et al, Management of acute cholecystitis in the laparoscopic era: results of a prospective, randomized clinical trial.
J Gastrointest Surg
2003;7:642–645.
12850677
A study of 145 patients randomised to early laparoscopic cholecystectomy within the first 7 days (early;
n
= 71) or to interval cholecystectomy at 6–8 weeks (late;
n
= 74). In the late group, 26% failed conservative therapy and required urgent laparoscopic cholecystectomy. On an intention-to-treat basis, analysis demonstrated no significant difference in conversion rates (early 31% vs. delayed 29%;
P
= 0.78) or complications, although one major bile duct injury occurred in the delayed group. There was a reduction in overall hospital stay (early 5, range 3–63 days, vs. delayed 8, range 4–50 days;
P
< 0.05).
9.
Gurusamy, K., Samraj, K., Gluud, C., et al, Meta-analysis of randomised controlled trials on the safety and effectiveness of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.
Br J Surg
2010;97:141–150.
20035546
This meta-analysis of five randomised controlled trials demonstrated no difference in conversion rate or incidence of bile duct injury and a shorter total hospital stay in the early surgery group.
10.
Kiviluoto, T., Siren, J., Luukkonen, P., et al, Randomised trial of laparoscopic versus open cholecystectomy for acute and gangrenous cholecystitis.
Lancet
1998;351:321–325.
9652612
There was a significantly lower complication rate in the laparoscopic group, with shorter hospital stay and quicker return to work.
11.
Lau, W.Y., Yuen, W.K., Chu, K.W., et al, Systemic antibiotic regimens for acute cholecystitis treated by early cholecystectomy.
Aust N Z J Surg
1990;60:539–543.
2113376
In a randomised trial of 203 patients, the continuation of cefamandole for 12 hours after surgery had equal efficacy with a prolonged dosage schedule of 7 days but was associated with fewer adverse drug reactions.
12.
Lo, L.D., Vogelzang, R.L., Braun, M.A., et al, Percutaneous cholecystostomy for the diagnosis and treatment of acute calculous and acalculous cholecystitis.
J Vasc Interv Radiol
1995;6:629–634.
7579876
13.
McGahan, J.P., Lindfors, K.K., Percutaneous cholecystostomy: an alternative to surgical cholecystostomy for acute cholecystitis?
Radiology
1989;173:481–485.
2678261
14.
Ito, K., Fujita, N., Noda, Y., et al, Percutaneous cholecystostomy versus gallbladder aspiration for acute cholecystitis: a prospective randomized controlled trial.
AJR Am J Roentgenol
2004;183:193–196.
15208137
15.
Hatzidakis, A.A., Prassopoulos, P., Petinarakis, I., et al, Acute cholecystitis in high-risk patients: percutaneous cholecystostomy vs conservative treatment.
Eur Radiol
2002;12:1778–1784.
12111069
A randomised trial of 123 patients with acute cholecystitis. Rates of clinical resolution and mortality were similar between the percutaneous cholecystostomy and conservative therapy groups.
16.
Kortram, K., van Ramshorst, B., Bollen, T.L., et al. Acute cholecystitis in high risk surgical patients: percutaneous cholecystostomy versus laparoscopic cholecystectomy (CHOCOLATE Trial): study protocol for a randomized controlled trial.
Trials
. 2012;13:7.
17.
Vetrhus, M., Soreide, O., Nesvik, I., et al, Acute cholecystitis: delayed surgery or observation. A randomized clinical trial.
Scand J Gastroenterol
2003;38:985–990.
14531537
18.
McDermott, V.G., Arger, P., Cope, C., Gallstone recurrence and gallbladder function following percutaneous cholecystolithotomy.
J Vasc Interv Radiol
1994;5:473–478.
8054750
19.
Courtois, C.S., Picus, D.D., Hicks, M.E., et al, Percutaneous gallstone removal: long-term follow-up.
J Vasc Interv Radiol
1996;7:229–234.
9007802
20.
Hellstern, A., Leuschner, U., Benjaminov, A., et al, Dissolution of gallbladder stones with methyl tert-butyl ether and stone recurrence: a European survey.
Dig Dis Sci
1998;43:911–920.
9590398
21.
Hernandez Estrada, A.I., Aguirre Osete, X., Pedraza Gonzalez, L.A., Laparoscopic cholecystectomy in pregnancy. Five years experience at the Spanish Hospital of Mexico and literature review.
Ginecol Obstet Mex
2011;79:200–205.
21966807
22.
Dhupar, R., Smaldone, G.M., Hamad, G.G., Is there a benefit to delaying cholecystectomy for symptomatic gallbladder disease during pregnancy?
Surg Endosc
2010;24:108–112.
19517178
23.
Chiappetta Porras, L.T., Nápoli, E.D., Canullán, C.M., et al, Minimally invasive management of acute biliary tract disease during pregnancy.
HPB Surg
2009;2009:829020.
19606252
24.
Glenn, F., Becker, C.G., Acute acalculous cholecystitis. An increasing entity.
Ann Surg
1982;195:131–136.
7055388
25.
Inoue, T., Mishima, Y., Postoperative acute cholecystitis: a collective review of 494 cases in Japan.
Jpn J Surg
1988;18:35–42.
3290556
26.
Devine, R.M., Farnell, M.B., Mucha, P., Jr., Acute cholecystitis as a complication in surgical patients.
Arch Surg
1984;119:1389–1393.
6508524
27.
Hakala, T., Nuutinen, P.J., Ruokonen, E.T., et al, Microangiopathy in acute acalculous cholecystitis.
Br J Surg
1997;84:1249–1252.
9313705
28.
Helbich, T.H., Mallek, R., Madl, C., et al, Sonomorphology of the gallbladder in critically ill patients. Value of a scoring system and follow-up examinations.
Acta Radiol
1997;38:129–134.
9059416
29.
Kalliafas, S., Ziegler, D.W., Flancbaum, L., et al, Acute acalculous cholecystitis: incidence, risk factors, diagnosis, and outcome.
Am Surg
1998;64:471–475.
9585788
30.
Kalff, V., Froelich, J.W., Lloyd, R., et al, Predictive value of an abnormal hepatobiliary scan in patients with severe intercurrent illness.
Radiology
1983;146:191–194.
6849044
31.
Almeida, J., Sleeman, D., Sosa, J.L., et al, Acalculous cholecystitis: the use of diagnostic laparoscopy.
J Laparoendosc Surg
1995;5:227–231.
7579674
32.
Boland, G.W., Lee, M.J., Leung, J., et al, Percutaneous cholecystostomy in critically ill patients: early response and final outcome in 82 patients.
AJR Am J Roentgenol
1994;163:339–342.
8037026
33.
Shirai, Y., Tsukada, K., Kawaguchi, H., et al, Percutaneous transhepatic cholecystostomy for acute acalculous cholecystitis.
Br J Surg
1993;80:1440–1442.
8252358
34.
Sugiyama, M., Tokuhara, M., Atomi, Y., Is percutaneous cholecystostomy the optimal treatment for acute cholecystitis in the very elderly?
World J Surg
1998;22:459–463.
9564288
35.
Shapiro, M.J., Luchtefeld, W.B., Kurzweil, S., et al, Acute acalculous cholecystitis in the critically ill.
Am Surg
1994;60:335–339.
8161083
36.
Csendes, A., Burdiles, P., Maluenda, F., et al, Simultaneous bacteriologic assessment of bile from gallbladder and common bile duct in control subjects and patients with gallstones and common duct stones.
Arch Surg
1996;131:389–394.
8615724
37.
Sung, J.J., Lyon, D.J., Suen, R., et al, Intravenous ciprofloxacin as treatment for patients with acute suppurative cholangitis: a randomized, controlled clinical trial.
J Antimicrob Chemother
1995;35:855–864.
7559196
A randomised trial assessing single antibiotic therapy demonstrated that intravenous ciprofloxacin alone improved the clinical condition in 85% of patients and had similar efficacy to a combination of ceftazidime, ampicillin and metronidazole.
38.
Csendes, A., Diaz, J.C., Burdiles, P., et al, Risk factors and classification of acute suppurative cholangitis.
Br J Surg
1992;79:655–658.
1643478
39.
Balthazar, E.J., Birnbaum, B.A., Naidich, M., Acute cholangitis: CT evaluation.
J Comput Assist Tomogr
1993;17:283–289.
8454756
40.
Thompson, J.E., Jr., Pitt, H.A., Doty, J.E., et al, Broad spectrum penicillin as an adequate therapy for acute cholangitis.
Surg Gynecol Obstet
1990;171:275–282.
2218831
A randomised clinical trial involving 96 patients with acute cholangitis in which piperacillin had similar efficacy to combination therapy with ampicillin and tobramycin, achieving clinical cure or significant improvement in 70% of patients.
41.
Lai, E.C., Tam, P.C., Paterson, I.A., et al, Emergency surgery for severe acute cholangitis. The high-risk patients.
Ann Surg
1990;211:55–59.
2294844
Retrospective study of 86 patients. All patients had ductal exploration under general anaesthesia. Study identifies markers of ‘high risk’: comorbidity, pH < 7.4, total bilirubin > 90 μmol/L, platelet count < 150 × 10
9
/L and serum albumin < 30 g/L. For high-risk patients, non-operative intervention may be preferable.
42.
Lai, E.C., Mok, F.P., Tan, E.S., et al, Endoscopic biliary drainage for severe acute cholangitis.
N Engl J Med
1992;326:1582–1586.
1584258
A randomised controlled trial comparing endoscopic biliary drainage with surgical decompression in 82 patients with severe acute cholangitis as manifested by signs of shock or progression of the disease despite appropriate antibiotics. In those undergoing endoscopic therapy there were fewer complications (34% vs. 66%;
P
> 0.05) but more importantly a significant reduction in mortality (10% vs. 32%;
P
< 0.03).
43.
, Tokyo guidelines for the management of acute cholangitis and cholecystitis. Proceedings of a consensus meeting, April 2006, Tokyo, Japan. J Hepatobiliary Pancreat Surg. 2007;14:1–121.
44.
Lee, D.W., Chan, A.C., Lam, Y.H., et al, Biliary decompression by nasobiliary catheter or biliary stent in acute suppurative cholangitis: a prospective randomized trial.
Gastrointest Endosc
2002;56:361–365.
12196773
45.
Pessa, M.E., Hawkins, I.F., Vogel, S.B., The treatment of acute cholangitis. Percutaneous transhepatic biliary drainage before definitive therapy.
Ann Surg
1987;205:389–392.
3566375
46.
Boerma, D., Rauws, E.A., Keulemans, Y.C., et al, Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: a randomised trial.
Lancet
2002;360:761–765.
12241833
47.
Targarona, E.M., Ayuso, R.M., Bordas, J.M., et al, Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bileduct calculi in high-risk patients.
Lancet
1996;347:926–929.
8598755
48.
Bradley, E.L., 3rd., A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992.
Arch Surg
1993;128:586–590.
8489394