Description of the condition
The pancreas is an abdominal organ that secretes several digestive enzymes into the pancreatic ductal system that empties into the small bowel. It also lodges the Islets of Langerhans, which secrete several hormones including insulin (NCBI 2011a). Acute pancreatitis is a sudden inflammatory process in the pancreas, with variable involvement of adjacent organs or other organ systems (Bradley 1993). Depending upon the presence of organ failure (such as kidneys, lungs or blood circulation) and the presence of local complications such as necrosis (destruction with liquefaction of tissues), an abscess (collection of pus) or pseudocyst (circumscribed collection of fluid without a cellular lining of the collection), pancreatitis can be classified as acute severe pancreatitis or acute mild pancreatitis (Bradley 1993). Patients with severe pancreatitis have organ failure or local complications, or both, while those with mild pancreatitis do not have such features (Bradley 1993).
There are regional variations in the incidence of first attacks of pancreatitis ranging from 10 per 100,000 in England to 44 per 100,000 in the USA (Spanier 2008). In European countries other than England, such as Germany, Sweden, Norway, Denmark, Netherlands and Finland, the incidence of first attacks of pancreatitis ranges between 15 and 37 per 100,000 (Omdal 2011; Sandzen 2009; Spanier 2008). The main reason for the differences in the incidence of first attacks of pancreatitis is considered to be the differences in alcohol consumption (Spanier 2008). There has been an increase in the incidence of pancreatitis worldwide (Spanier 2008). The two main causes of acute pancreatitis are gallstones and alcohol, accounting for more than 80% of acute pancreatitis (Spanier 2008). Gallstones can cause temporary obstruction at the ampulla of Vater, which is a common channel shared by the bile duct and pancreatic duct, resulting in increased pressure within the pancreas leading on to enzyme activation within the pancreas and acute pancreatitis (Wang 2009).
Removal of the gallbladder (cholecystectomy) is the definitive treatment for prevention of further attacks of acute gallstone pancreatitis if the patient is suitable for surgery. Current British Society of Gastroenterology guidelines state that all patients with biliary pancreatitis (gallstone related pancreatitis) should undergo cholecystectomy during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks, based on a low level of evidence (BSG 2005).
Laparoscopic removal (key-hole surgery) of the gallbladder is the currently preferred way of cholecystectomy (Ballal 2009; Dolan 2009; Harboe 2011). The standard laparoscopic procedure involves inflating the stomach (tummy) with carbon dioxide (pneumoperitoenum), introducing cameras and instruments through four small incisions (two of about 1 cm and two of about 0.5 cm) and removing the gallbladder. Various variations include lifting the anterior abdominal wall (front of the tummy) rather than inflating the tummy and using fewer ports and smaller incisions (Gurusamy 2010; Gurusamy 2012; Ma 2011).
Description of the intervention
There is no universally accepted definition of early laparoscopic cholecystectomy. In patients with mild acute gallstone pancreatitis, we consider any laparoscopic cholecystectomy performed within three days after onset of pancreatitis as early laparoscopic cholecystectomy. The reason for choosing the arbitrary three days is that this allows time for the clinicians to make the diagnosis of mild pancreatitis and organise the laparoscopic cholecystectomy. We considered more than three days as delayed laparoscopic cholecystectomy.
In patients with severe acute gallstone pancreatitis, we consider any laparoscopic cholecystectomy performed during the same admission as early laparoscopic cholecystectomy. This is because the patients may be at high risk of anaesthetic and surgical complications until recovery from systemic organ failure. In these patients, we considered laparoscopic cholecystectomy performed in a later admission as delayed laparoscopic cholecystectomy.
How the intervention might work
Delaying laparoscopic cholecystectomy exposes the patient to a risk of potentially fatal recurrent acute pancreatitis (BSG 2005). On the other hand, considering that pancreatitis is a systemic disorder, the delay by 72 hours allows the patient to recover fully prior to laparoscopic cholecystectomy in the case of mild pancreatitis patients. In the case of severe pancreatitis, the delay may allow the inflammation to settle down completely before the laparoscopic cholecystectomy.
Why it is important to do this review
As mentioned previously, current British Society of Gastroenterology guidelines state that all patients with biliary pancreatitis should undergo cholecystectomy (open or laparoscopic) during the same hospital admission, unless a clear plan has been made for definitive treatment within the next two weeks, based on a low level of evidence (BSG 2005). It is not clear whether delaying surgery after diagnosis of mild acute gallstone pancreatitis is beneficial or harmful to these patients. It is not clear whether delaying surgery for another two weeks, or more, is beneficial or harmful to the patients with either mild or severe acute pancreatitis. Ito et al showed in a retrospective cohort study that even a delay of two weeks after discharge exposes the patients to complications of gallstones including recurrent pancreatitis (Ito 2008). Wilson et al performed a literature review of early versus delayed cholecystectomy after acute pancreatitis and concluded that patients with mild gallstone pancreatitis should have cholecystectomy during the index admission within 48 hours of arrival and that patients with more severe disease should undergo the procedure at a later time, which could even be weeks or months after the pancreatitis episode depending on the clinical circumstances (Wilson 2010). There has been no Cochrane review assessing whether laparoscopic cholecystectomy should be performed early or be delayed in patients with acute gallstone pancreatitis.