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World J Gastroenterol. Sep 14, 2016; 22(34): 7708-7717
Published online Sep 14, 2016. doi: 10.3748/wjg.v22.i34.7708
Management of patients after recovering from acute severe biliary pancreatitis
Georgia Dedemadi, Manolis Nikolopoulos, Ioannis Kalaitzopoulos, George Sgourakis
Georgia Dedemadi, Manolis Nikolopoulos, Ioannis Kalaitzopoulos, Department of Surgery, Sismanoglio-Amalia Fleming Hospital, Melissia, 15127 Athens, Greece
George Sgourakis, Department of Surgery, Furness General Hospital, Dalton Lane, Barrow-in-Furness, Cumbria LA14 4LF, United Kingdom
Author contributions: Dedemadi G, Nikolopoulos M and Sgourakis G designed the research, wrote the paper, and contributed critical revision; Dedemadi G, Nikolopoulos M and Kalaitzopoulos I analyzed and interpreted the data, and drafted the paper; all authors approved the final version.
Conflict-of-interest statement: The authors have no conflict of interest to report.
Open-Access: This article is an open-access article which was selected by an in-house editor and fully peer-reviewed by external reviewers. It is distributed in accordance with the Creative Commons Attribution Non Commercial (CC BY-NC 4.0) license, which permits others to distribute, remix, adapt, build upon this work non-commercially, and license their derivative works on different terms, provided the original work is properly cited and the use is non-commercial. See: http://creativecommons.org/licenses/by-nc/4.0/
Correspondence to: Georgia Dedemadi, MD, PhD, FACS, Department of Surgery, Sismanoglio-Amalia Fleming Hospital, 14, 25th Martiou str, Melissia, 15127 Athens, Greece. gdedemadi@gmail.com
Telephone: +30-210-6033361 Fax: +30-210-6033361
Received: March 26, 2016
Peer-review started: March 27, 2016
First decision: May 12, 2016
Revised: June 7, 2016
Accepted: June 15, 2016
Article in press: June 15, 2016
Published online: September 14, 2016
Processing time: 165 Days and 13.5 Hours
Abstract

Cholelithiasis is the most common cause of acute pancreatitis, accounting 35%-60% of cases. Around 15%-20% of patients suffer a severe attack with high morbidity and mortality rates. As far as treatment is concerned, the optimum method of late management of patients with severe acute biliary pancreatitis is still contentious and the main question is over the correct timing of every intervention. Patients after recovering from an acute episode of severe biliary pancreatitis can be offered alternative options in their management, including cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy, or no definitive treatment. Delaying cholecystectomy until after resolution of the inflammatory process, usually not earlier than 6 wk after onset of acute pancreatitis, seems to be a safe policy. ERCP and sphincterotomy on index admission prevent recurrent episodes of pancreatitis until cholecystectomy is performed, but if used for definitive treatment, they can be a valuable tool for patients unfit for surgery. Some patients who survive severe biliary pancreatitis may develop pseudocysts or walled-off necrosis. Management of pseudocysts with minimally invasive techniques, if not therapeutic, can be used as a bridge to definitive operative treatment, which includes delayed cholecystectomy and concurrent pseudocyst drainage in some patients. A management algorithm has been developed for patients surviving severe biliary pancreatitis according to the currently published data in the literature.

Keywords: Biliary pancreatitis; Cholecystectomy; Endoscopic retrograde cholangiopancreatography; Sphincterotomy; Pseudocyst; Walled-off necrosis

Core tip: There is a paucity of data as to which of the following treatment options, including cholecystectomy, endoscopic retrograde cholangiopancreatography and sphincterotomy, drainage techniques for fluid collections and pseudocysts, or no definitive treatment, is the optimal for patients after recovering from an acute episode of severe biliary pancreatitis. The complexity of pancreatitis regarding its course, patient’s performance status, and the variety of available interventions should be taken into consideration, raising the need for multidisciplinary management and individualization of every case.