Adherence to the guidelines for treatment of mild biliary acute pancreatitis in the setting of tertiary center in the Czech Republic

Česká verzia

Authors: Oldřich Stibůrek ¹; Jan Trna ¹; Michal Šenkyřík ¹; Vladimír Prochazka ²; Zdeněk Kala ²; Aleš Hep ¹
Authors place of work: Interní gastroenterologická klinika LF MU a FN Brno, pracoviště Bohunice, přednosta prof. MUDr. Aleš Hep, CSc. ¹; Chirurgická klinika LF MU a FN Brno, pracoviště Bohunice, přednosta prof. MUDr. Zdeněk Kala, CSc. ²
Published in the journal: Vnitř Lék 2014; 60(5-6): 417-422
Category: Original Contributions

Summary

Introduction:
Cholecystectomy (CCX) represents the crucial procedure in preventing relapses of biliary acute pancreatitis (BAP). Endoscopic papilosphincterotomy (EPST) represent an acceptable alternative in patients unsuitable for surgery. Current guidelines recommend patients with mild BAP to undergo CCX in 2 maximally 4 weeks following discharge from the hospital, ideally during the same hospital stay. Adherence to the guidelines differs significantly between particular countries and institutions.

Aim:
To evaluate adherence to the guidelines of BAP management in conditions of tertiary hospital in the Czech Republic.

Methods:
Retrospective analysis of consecutive patients hospitalized in the Clinic of Gastroenterology, University Hospital Brno for acute pancreatitis in years 2007–2012. Cases with both sonographic findings of lithiasis/sludge and 3-fold AST/ALT elevation were considered of clearly biliary etiology.

Results:
We identified 328 patients treated for acute pancreatitis. Clearly biliary etiology was identified in 116 cases (54 male, 62 female). From 114 analyzed patients with complete documentation 81 underwent CCX, 23 were not operated and 10 cases were patients with history of previous CCX. Total mortality of the group was 5.3 %. Out of 81 patients who had CCX was 48 cases of mild BAP. CCX was done during the same hospital stay and/or within 4 weeks from dismissal in 20 patients, therefore, current guidelines were followed in 41.7 % of our study group. Eighteen out of the remaining 28 patients underwent ERCP with EPST. Therefore, within 4 weeks from dismissal 75 % of our patients underwent a procedure (CCX and/or EPST) with a potential to reduce the risk of BAP recurrence. Conclusion: When longer (4 weeks) interval between mild BAP and CCX is applied, the current guidelines are followed in 41.7 % of patients treated at our institution, which is comparable with the literature data. As much as 75 % of our patients underwent a procedure (CCX and/or EPST) with a potential to reduce the risk of BAP recurrence. However, only 12.5 % of index CCX is not favorable outcome that needs improvement. Similar difficulties are being dealt with in the most countries in the World.

Key words:
biliary acute pancreatitis – ERCP – guidelines – cholecystectomy – papilosphincterotomy

Zdroje

1. Gullo L, Migliori M, Olah A et al. Acute pancreatitis in five European countries: Etiology and mortality. Pancreas 2002; 24(3): 223–227.

2. Ros E, Navarro S, Conxita B et al. Occult microlithiasis in “idiopathic” acute pancreatitis: Prevention of relapses by cholecystectomy or ursodeoxycholic acid therapy. Gastroenterology 1991; 101(6): 1701–1709.

3. Lee SP, Nicholls JF, Park HZ. Biliary sludge as a cause of acute pancreatitis. N Eng J Med 1992; 326(9): 589–593.

4. Levy M. The hunt for microlithiasis in idiopathic acute recurrent pancreatitis: Should we abandon the search or intensify our efforts? Gastrointest Endosc 2002; 55(2): 286–293.

5. Venneman NG, van Brummelen SE, van Berge-Henegouwen GP et al. Microlithiasis: an important cause of “idiopathic” acute pancreatitis? Ann Hepatol 2003; 2(1): 30–35.

6. Saraswat VA, Sharma BC, Agarwal DK et al. Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: Response to therapy. J Gastroenterol Hepatol 2004; 19(10): 1206–1211.

7. Nebiker CA, Frey DM, Hamel CT et al. Early versus delayed cholecystectomy in patients with biliary acute pancreatitis. Surgery 2009; 145(3): 260–264.

8. Gullo L, Migliori M, Pezzilli R et al. An update on recurrent acute pancreatitis: data from five European countries. Am J Gastroenterol 2002; 97(8):1959–1962.

9. Uomo G, Manes G, Laccetti M et al. Endoscopic sphincterotomy and recurrence of acute pancreatitis in gallstone patients considered unfit for surgery. Pancreas 1997; 14(1): 28–31.

10. Kaw M, Al-Antably Y, Kaw P. Management of gallstone pancreatitis: cholecystectomy or ERCP and endoscopic sphincterotomy. Gastrointest Endosc 2002; 56(1): 61–65.

11. Sarosi G, Rege RV. Biliary pancreatitis. J Gastrointest Surg 2006; 10(8):1170–1179.

12. Billi P, Barakat B, D’Imperio N et al. Relapses of biliary acute pancreatitis in patients with previous attack of biliary pancreatitis and gallbladder in situ. Dig Liver Dis 2003; 35(9): 653–655.

13. UK Working Party on Acute Pancreatitis. UK guidelines for the management of acute pancreatitis. Gut 2005; 54(Suppl 3): S1-S9.

14. Forsmark CE, Baillie J (AGA Institute Clinical Practice and Economics Committee; AGA Institute Governing Board). AGA Institute Technical Review on Acute Pancreatitis. Gastroenterology 2007; 132(5): 2022–2044.

15. Uhl W, Warshaw A, Imrie C et al. IAP Guidelines for the Surgical Management of Acute Pancreatitis. Pancreatology 2002; 2(6): 565–573.

16. Clain JE, Pearson RK Evidence-based approach to idiopathic pancreatitis. Curr Gastroent Rep 2002; 4(2): 128–134.

17. Banks PA, Bollen TL, Dervenis C et al. Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62(1): 102–111.

18. Tenner S, Dubner H, Steinberg W. Predicting gallstone pancreatitis with laboratory parameters: a meta-analysis. Am J Gastroenterol 1994; 89(10): 1863–1866.

19. Sargen K, Kingsnorth AN. Management of Gallstone Pancreatitis: Effects of Deviation from Clinical Guidelines. JOP 2001; 2(5): 317–322.

20. del Pozo D, Tabernero S, Poves E et al. Usefulness of endoscopic ultrasonography in the clinical suspicion of biliary disease. Rev Esp Enferm Dig 2011; 103(7): 345–348.

21. De Rai P et al. Surgical management of acute pancreatitis in Italy: lessons from a prospective multicentre study. HPB (Oxford) 2010; 12(9): 597–604.

22. Chiang D, Thompson G. Management of acute gallstone pancreatitis: so the story continues. ANZ J Surg 2008; 78(1–2): 52–54.

23. Sanjay P et al. Management Guidelines for Gallstone Pancreatitis. Are the Targets Achievable? JOP 2009; 10(1): 43–47.

24. Frakes JT. Acute biliary pancreatitis: When ERCP is needed? ASGE Clinical Update 1999; 7: 1–4.

25. van Baal MC, Besselink MG, Bakker OJ et al. Timing of cholecystectomy after mild biliary pancreatitis: a systematic review. Ann Surg 2012; 255(5): 860–866.

26. Monkhouse S, Court E, Dash I et al. Two-week target for laparoscopic cholecystectomy following gallstone pancreatitis is achievable and cost neutral. Br J Surg 2009; 96(7): 751–755.