Timing of endoscopic retrograde cholangiopancreatography in acute biliary pancreatitis without cholangitis: a nationwide inpatient cohort study

Indication and Timing of Cholecystectomy in Acute Biliary Pancreatitis - Systematic Review

Acute biliary pancreatitis (ABP) poses significant challenges in determining the optimal timing and approach for cholecystectomy, particularly in mild, moderately severe, and severe forms. This article reviews the existing literature on cholecystectomy timing and its impact on outcomes in ABP. A systematic literature search yielded 41 relevant articles from PubMed and Scopus databases. In mild ABP, early cholecystectomy within 72 hours of onset is increasingly favoured due to reduced technical difficulty and lower risk of recurrent pancreatitis. Conversely, delayed cholecystectomy, although traditionally practiced, may lead to higher recurrence rates and prolonged hospital stays. For moderate severe ABP, evidence remains limited, but early cholecystectomy appears to decrease hospital stay without increasing perioperative complications. In severe ABP, consensus suggests delaying cholecystectomy until peripancreatic collections resolve, typically 6 to 10 weeks post-onset, to minimize surgical morbidity. The role of endoscopic retrograde cholangiopancreatography (ERCP) alongside cholecystectomy remains contentious, with guidelines recommending its use in specific scenarios such as cholangitis or biliary obstruction. However, routine ERCP in mild ABP lacks robust evidence and may increase complications. Challenges persist regarding the management of residual choledocholithiasis post-ABP, highlighting the need for improved diagnostic criteria and management protocols. Overall, this review underscores the evolving landscape of cholecystectomy timing in ABP and provides insights into current best practices and areas for future research.

Utility of Urgent Endoscopic Retrograde Cholangiopancreatography in Patients with Predicted Mild Acute Pancreatitis and Cholestasis

BACKGROUND

Endoscopic retrograde cholangiopancreatography (ERCP) within 72 h is suggested for patients presenting with acute biliary pancreatitis (ABP) and biliary obstruction without cholangitis. This study aimed to identify if urgent ERCP (within 24 h) improved outcomes compared to early ERCP (24-72 h) in patients admitted with predicted mild ABP.

METHODS

Patients admitted for predicted mild ABP defined as a bedside index of severity in acute pancreatitis score < 3 and underwent ERCP for biliary obstruction within 72 h of presentation during the study period were included. Patients with prior biliary sphincterotomy or surgically altered anatomy preventing conventional ERCP were excluded. The primary outcome was the development of moderately severe or severe pancreatitis based on the revised Atlanta classification. Secondary outcomes were the length of hospital stay, the need for ICU admission, and ERCP-related adverse events (AEs).

RESULTS

Of the identified 166 patients, baseline characteristics were similar between both the groups except for the WBC count (9.4 vs. 8.3/µL; p < 0.044) and serum bilirubin level (3.0 vs. 1.6 mg/dL; p < 0.0039). Biliary cannulation rate and technical success were both high in the overall cohort (98.8%). Urgent ERCP was not associated with increased development of moderately severe pancreatitis (10.4% vs. 15.7%; p = 0.3115). The urgent ERCP group had a significantly shorter length of hospital stay [median 3 (IQR 2-3) vs. 3 days (IQR 3-4), p < 0.01].

CONCLUSION

Urgent ERCP did not impact the rate of developing more severe pancreatitis in patients with predicted mild ABP but was associated with a shorter length of hospital stay and a lower rate of hospital readmission.

Systematic Review: Impact of Social Determinants of Health on the Management and Prognosis of Gallstone Disease

Background:

Due to its prevalence, gallstone disease is a major public health issue. It affects diverse patient populations across various socioeconomic levels. Socioeconomic and geographic deprivation may impact both morbidity and mortality associated with digestive diseases, such as biliary tract disease.

Aim:

The aim of this systematic review was to review the available data on the impact of socioeconomic determinants and geographic factors on gallstone disease and its complications.

Methods:

This systematic review was conducted following Preferred Reporting Items for Systematic Reviews and Meta-Analyses guidelines. The MEDLINE and Web of Science databases were searched by two investigators to retrieve studies about the impact of income, insurance status, hospital status, education level, living areas, and deprivation indices on gallstone disease. Thirty-seven studies were selected for this review.

Results:

Socially disadvantaged populations appear to be more frequently affected by complicated or severe forms of gallstone disease. The prognosis of biliary tract disease is poor in these populations regardless of patient status, and increased morbidity and mortality were observed for acute cholangitis or subsequent cholecystectomy. Limited or delayed access and low-quality therapeutic interventions could be among the potential causes for this poor prognosis.

Conclusions:

This systematic review suggests that socioeconomic determinants impact the management of gallstone disease. Enhanced knowledge of these parameters could contribute to improved public health policies to manage these diseases.

CRP and ALT Levels in Individuals with Acute Biliary Pancreatitis after Endoscopic Retrograde Cholangiopancreatography and Endoscopic Sphincterotomy

Objective

The goal of this study was to see how effective endoscopic retrograde cholangiopancreatography combined with endoscopic sphincterotomy was in treating acute biliary pancreatitis and how it affected CRP and ALT levels.

Methods

This analysis is based on a 100-patient acute pancreatitis (ABP) study conducted at our institution from June 2019 to June 2020. They were divided into two groups of 50 cases each, the control group and the observational group, according to the random number table. Endoscopic sphincterotomy and ERCP were performed on the observation group instead of open surgery on the control group as a point of comparison (EST). The followings were compared including abdominal pain relief duration, blood amylase recovery duration, and hospital stay duration, as well as Serum C-reactive protein (CRP), interleukin-6 (IL-6), and tumor necrosis factor-α (TNF-α) level; the ALT, AST, and GGT levels of the two groups were compared, as well as the occurrence of problems in both groups.

Results

The observation group had a significantly shorter duration of abdominal pain, blood amylase recovery, and hospital stay. Presurgery CRP, IL-6, and TNF-α levels in both groups were significantly lower in the observation group than in the control group. According to the results of the study, both groups saw significant decreases in ALT, AST, and GGT after surgery; however, the levels of these markers in both groups were significantly lower in the observation group after surgery than in the control group. The observation group's (14.00 percent) complication rate was substantially lower.

Conclusion

ERCP and EST in the treatment of ABP can not only successfully improve clinical indexes and facilitate the recovery of patients but also reduce the levels of CRP and alt, reduce the level of inflammation, and enhance renal function, with reduced problems, which has a high clinical reference value.