Gallstone Pancreatitis The
Question of Time
Jon M. Burch, MD; David V. Feliciano, MD; Kenneth L. Mattox, MD; \s=b\ Two hundred consecutive patients with gallstone pancreatitis were treated during a 6-year period; 92 patients were operated on after the acute attack subsided but during the same admission (group 1), 102 patients were discharged after recovery and scheduled for elective surgery (group 2), and the conditions of 6 patients deteriorated and they underwent emergency operation (group 3). All patients in group 3 had hemorrhagic pancreatitis. Mortalities for groups 1, 2, and 3 were 0%, 0%, and 50%, respectively. Although the outcome of patients in groups 1 and 2 was similar, only 60 of 102 patients in group 2 had their treatment completed. Furthermore, 29 (44%) of 65 patients who were followed up in group 2 suffered recurrent pancreatitis or biliary tract disease before elective surgery. The timing of surgery in patients whose conditions improve is not critical; however, patients whose conditions deteriorate after admission have severe disease with high morbidity and mortality.
(Arch Surg. 1990;125:853-860)
century, cholecystectomy Since patients prevent concept surgical gallstone pancreatitis.12 Although
has been the middle of this with advocated to recurrent attacks in of the treatment is generally accepted, there continues to be dis¬ agreement regarding the timing of surgery. Those who sup¬ port emergency intervention believe that the progression of pancreatitis can be interrupted by the prompt relief of ob¬ struction at the ampulla of Vater.34 Others recommend delay¬ ing surgery until the acute attack has subsided and then performing cholecystectomy during the same admission.5"8 Traditionally, surgery has been delayed until a subsequent admission to allow complete recovery from the attack.9 This approach, however, has fallen into disfavor because of the risk of recurrent pancreatitis.5"79,10 We have been conservative in adopting cholecystectomy during the initial admission but have recognized the problem of recurrence. This report summarizes our experience during transition toward same-admission surgery for patients with
gallstone pancreatitis.
PATIENTS AND METHODS
January 1983 to January 1989, a total of 200 consecutive with gallstone pancreatitis were treated at the Ben Taub General Hospital in Houston, Tex. The patients ranged in age from 16 From
patients
to 91 years, with a mean age of 36 years. The third decade of life was most frequently represented, with 35% of patients being between the ages of 20 and 29 years (Fig 1). The ethnic distribution for both sexes is listed in Table 1. Hispanic women dominated the series, with a
majority of 58%.
Accepted for publication March 21,1990. From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine and Ben Taub General Hospital, Houston, Texas. Dr Feliciano is now with the Department of Surgery, University of Rochester (NY). Read before the 97th Annual Meeting of the Western Surgical Association, St Louis, Mo, November 15,1989. Reprint requests to Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030 (Dr Burch).
George L. Jordan, Jr, MD
Diagnosis The preoperative diagnosis of gallstone pancreatitis hinged on three elements: characteristic history and physical examination find¬ ings, hyperamylasemia, and the documentation of gallstones. Most patients gave a history of upper-abdominal pain, with or without radiation to the back, associated with nausea and vomiting. On exami¬ nation, right upper-quadrant or epigastric tenderness was present. Hyperamylasemia was not considered indicative of pancreatitis unless the value was elevated to three times the upper limit of normal (normal range, 34 to 122 U/L). Three patients in this series had maximal amylase values of less than 360 U/L, and each had confirma¬ tion of pancreatitis at laparotomy. Most patients had much higher values, with 163 (82%) having peak amylase levels of greater than 1000 U/L. Serum amylase was measured for several consecutive days. Figure 2 shows the median daily amylase values. Note that within 72 hours of admission, the median level fell to near the normal range. Preoperatively, ultrasonography was used to detect gallstones in all patients. This technique has been demonstrated to be accurate in 97% of patients at this institution.11 One patient with a minimally elevated amylase level was operated on for an acute abdomen; moder¬ ate to severe edematous pancreatitis was present, but no stones were detected in the gallbladder. After discharge, the patient suffered a recurrent attack, and ultrasonography documented gallstones on two separate occasions. A history of regular alcohol intake was obtained in eight patients, although none was obviously a chronic alcoholic. It could not be determined with certainty whether gallstones or alcohol was the etiologic agent. None of these patients had chronic pancreatitis at operation, although one did have evidence of cirrhosis on a liver
biopsy specimen.
The median values of liver function tests obtained on admission are shown in Table 2. When these levels were compared with normal laboratory values, all were found to be significantly elevated (Z test based on normal limits, P
Question of Time
Jon M. Burch, MD; David V. Feliciano, MD; Kenneth L. Mattox, MD; \s=b\ Two hundred consecutive patients with gallstone pancreatitis were treated during a 6-year period; 92 patients were operated on after the acute attack subsided but during the same admission (group 1), 102 patients were discharged after recovery and scheduled for elective surgery (group 2), and the conditions of 6 patients deteriorated and they underwent emergency operation (group 3). All patients in group 3 had hemorrhagic pancreatitis. Mortalities for groups 1, 2, and 3 were 0%, 0%, and 50%, respectively. Although the outcome of patients in groups 1 and 2 was similar, only 60 of 102 patients in group 2 had their treatment completed. Furthermore, 29 (44%) of 65 patients who were followed up in group 2 suffered recurrent pancreatitis or biliary tract disease before elective surgery. The timing of surgery in patients whose conditions improve is not critical; however, patients whose conditions deteriorate after admission have severe disease with high morbidity and mortality.
(Arch Surg. 1990;125:853-860)
century, cholecystectomy Since patients prevent concept surgical gallstone pancreatitis.12 Although
has been the middle of this with advocated to recurrent attacks in of the treatment is generally accepted, there continues to be dis¬ agreement regarding the timing of surgery. Those who sup¬ port emergency intervention believe that the progression of pancreatitis can be interrupted by the prompt relief of ob¬ struction at the ampulla of Vater.34 Others recommend delay¬ ing surgery until the acute attack has subsided and then performing cholecystectomy during the same admission.5"8 Traditionally, surgery has been delayed until a subsequent admission to allow complete recovery from the attack.9 This approach, however, has fallen into disfavor because of the risk of recurrent pancreatitis.5"79,10 We have been conservative in adopting cholecystectomy during the initial admission but have recognized the problem of recurrence. This report summarizes our experience during transition toward same-admission surgery for patients with
gallstone pancreatitis.
PATIENTS AND METHODS
January 1983 to January 1989, a total of 200 consecutive with gallstone pancreatitis were treated at the Ben Taub General Hospital in Houston, Tex. The patients ranged in age from 16 From
patients
to 91 years, with a mean age of 36 years. The third decade of life was most frequently represented, with 35% of patients being between the ages of 20 and 29 years (Fig 1). The ethnic distribution for both sexes is listed in Table 1. Hispanic women dominated the series, with a
majority of 58%.
Accepted for publication March 21,1990. From the Cora and Webb Mading Department of Surgery, Baylor College of Medicine and Ben Taub General Hospital, Houston, Texas. Dr Feliciano is now with the Department of Surgery, University of Rochester (NY). Read before the 97th Annual Meeting of the Western Surgical Association, St Louis, Mo, November 15,1989. Reprint requests to Department of Surgery, Baylor College of Medicine, 1 Baylor Plaza, Houston, TX 77030 (Dr Burch).
George L. Jordan, Jr, MD
Diagnosis The preoperative diagnosis of gallstone pancreatitis hinged on three elements: characteristic history and physical examination find¬ ings, hyperamylasemia, and the documentation of gallstones. Most patients gave a history of upper-abdominal pain, with or without radiation to the back, associated with nausea and vomiting. On exami¬ nation, right upper-quadrant or epigastric tenderness was present. Hyperamylasemia was not considered indicative of pancreatitis unless the value was elevated to three times the upper limit of normal (normal range, 34 to 122 U/L). Three patients in this series had maximal amylase values of less than 360 U/L, and each had confirma¬ tion of pancreatitis at laparotomy. Most patients had much higher values, with 163 (82%) having peak amylase levels of greater than 1000 U/L. Serum amylase was measured for several consecutive days. Figure 2 shows the median daily amylase values. Note that within 72 hours of admission, the median level fell to near the normal range. Preoperatively, ultrasonography was used to detect gallstones in all patients. This technique has been demonstrated to be accurate in 97% of patients at this institution.11 One patient with a minimally elevated amylase level was operated on for an acute abdomen; moder¬ ate to severe edematous pancreatitis was present, but no stones were detected in the gallbladder. After discharge, the patient suffered a recurrent attack, and ultrasonography documented gallstones on two separate occasions. A history of regular alcohol intake was obtained in eight patients, although none was obviously a chronic alcoholic. It could not be determined with certainty whether gallstones or alcohol was the etiologic agent. None of these patients had chronic pancreatitis at operation, although one did have evidence of cirrhosis on a liver
biopsy specimen.
The median values of liver function tests obtained on admission are shown in Table 2. When these levels were compared with normal laboratory values, all were found to be significantly elevated (Z test based on normal limits, P
