Acute pancreatitis is an acute inflammatory process involving the pancreatic gland. Many conditions determinate the onset of an acute pancreatitis, but the most common cause is constituted by gallstones . In most cases acute biliary pancreatisis (ABP) arises in a mild form and, after support therapy, the definitive treatment is represented by laparoscopic cholecystectomy (LC). With recurrence rates for gallstone pancreatitis reported as high as 63%  and with some of the repeat attacks occurring within 2 weeks of initial index presentation, most investigators have recommended cholecystectomy during the initial hospitalization [3,4]. On the other hand, some studies [5,6] showed that adherence to these guidelines is low and a high number of patients is readmitted to hospital for gallstonerelated sequels causing prolonged hospitalization and a high re-admission rate.
ABP posed another problem related to its pathogenetic process because the obstruction by calculi of the common channel that drains both the biliary and pancreatic ducts results in the inflammation of the glands. Approximately 45–70% of patients with mild ABP  have common bile duct stones (CBDS) found on endoscopic retrograde cholangiopancreatography (ERCP) or at surgery performed within 72h of admission. The majority of biliary stones pass spontaneously; however, risk of persistent ampullary obstruction increases with advanced patient age and stone size less than 5mm [8,9]. Persistent CBDS may increase ABP mortality rate due to their complications such as sepsis, hemorrhage, necrotizing pancreatitis.
In the present study was evaluated the efficacy, safety and the timing of LC and CBDS retrieval in the management of mild ABP.
A retrospective analysis of all patients admitted to our department in emergency for ABP during last 13 years was performed. Clinical diagnosis of ABP was confirmed by elevated pancreatic enzymes and ultrasound or Computer Tomography scan findings of cholelithiasis at time of hospital admission. The severity of the pancreatitis was evaluated by Ranson scoring system and patient’s with Ranson’s score of ≤3 were enrolled and scheduled for early LC.
Since 1997 in our department, a single-stage management of CBDS was the favorite approach avoiding pre-operative ERCP. Based on this management, patients were not assessed with colangio-pancreatic magnetic resonance in order to reduce the pre-surgery hospital stay. Patients were operated electively when symptoms had been settled and pancreatic enzymes tend to reduced. All procedures were performed under general anesthesia with the patient positioned supine. A four-port access was used: 12mm umbilical port for 30° telescope and insufflation; two
The nominal variables were compared using the chisquare test. P values
From January 2000 to November 2013, 293 consecutive patients (130 male and 163 female) with mild ABP underwent LC at the Emergency Surgery Unit, University of Pisa. Characteristics of patients are given in Table 1. The mean age was 65 years (range 21-94 years) whereas the mean interval from admission to surgery was 4,7 days (range 1-17 days).
Mean operative time was 104 min (range 45-360 min). The conversion rate was 1.3% (4 cases). Conversion to open surgery occurred because of adhesions (2 cases) and important inflammatory reaction involving Calot’s structures with impossibility to identify safetly the cystic duct (2 cases).
Table 1 Patient characteristics in the study group
During surgery CBDS was found in 68 patients (23.2%). Trans-cystic exploration was considered as a first choice in 56 cases (82%) but clearance of CBDS with this approach was achieved in 53 patients (77.9%). Reason of failure or rejection of this technique was: impacted stones, stones displaced to intra-hepatic ducts, inability to entrap stones and stones too big with respect to the cystic duct caliber. In such circumstances, other techniques such as choledochotomy (6 cases) or intra-operative ERCP with rendezvous technique (5 cases) were used. Overall successful rate of single step CBDS clearance was 94.1% (64 cases). Only in 4 patients a intra-operative clearance was not achieved; in these cases a drain was left into the common bile duct (Bracci’ catheter or T tube) and scheduled for post-operative ERCP. Patient was then discharged and the endoscopic procedure was performed within 4 weeks.
The mean post-operative hospital stay was 3,5 days (range 1-35 days). Twenty-five patients (8.5% of total) have one or more general or surgical complications. The last included surgical site bleeding (6 cases), duodenal leak (1 case), wound infection (2 cases) and worsening jaundice (1 case). All complications resolved conservatively with the exception of two patients who underwent angioembolization to stop ongoing bleeding from a ruptured abdominal wall vessel. Two patients (0.68% of total) were re-operated: for hemoperitoneum due to liver bad bleeding controlled laparoscopically (1 case) and for residual stones with worsening janduice and cholangitis in another case after failure of ERCP, leading to open surgery. Mortality rate was 0.34%.
During a mean follow up period of 10 months (range 1-29 months) none of the patients successfully treated showed a symptoms, signs, laboratory or radiological evidence of recurrent/retained CBDS. Early readmission were related to subhepatic fluid collection treated with percutaneous ultrasound-guided drainage in one case and for rectus sheath hematoma managed with arterial embolization in another patient who took anticoagulant therapy for pulmonary embolism. Also delayed readmissions were observed in the study: an incisional hernia developed in 2 patients after 4 months, requiring surgical repair.
As it’s showed in Table 2. age, time spending in the operative room and post-operative stay were significantly different between the group of patients who simple LC was performed (n=225) and the group of patients (n=68) in whom CBDS clearance was attempted. In fact, in this letter group the mean operative time (151 min vs. 91 min; p<0.05) and the post-operative stay (5,2 days vs. 3 days; p<0.05) were longer. No statistically significant differences were found in the other variables taking in considerations, in particular in the conversion and morbidity rate.
Abbreviations: LC-Laparoscopic Cholecystectomy; CBDS-Common Bile Duct Stones; POSH-Pre-Operative Hospital Stay; NS-Not statistically Significant
The timing of cholecystectomy in acute biliary pancreatitis is related to the severity of the inflammation. In a randomized study, Kelly and Wagner  stated that in patients with severe pancreatitis (Ranson signs>3) delayed open cholecystectomy was recommended because associated with lower mortality and morbidity when compared with early surgery. On the other hand, in patient with mild ABP, there was no differences in mortality and morbidity.'
Despite many finding of international guidelines, thetiming of definitive surgery in mild ABP in the laparoscopic era is still debated with a tendency to adhere to traditional method of interval LC thinking that in the acute setting the surgical procedure tend to be more difficult. Based on this hypothesis, in a recent study , patients were hospitalized until laboratory values and physical examination normalized, subsequently discharged home without cholecystectomy, and then scheduled for an elective cholecystectomy as an outpatient within 2 weeks after discharge. In a large observational study in Sweden  involving more than 1500 patients with mild ABP, up to 10% of cases LC was performed as a interval procedure within 30 days from index admission. Moreover in 68% of total neither cholecystectomy nor sphincterotomy within 30 days was considered. In our opinion, the interval surgery or the only conservative management creates unnecessary delays in surgical therapy and a potential for recurrent pancreatitis. This concern was validated by Ito et al , who reported that 32% of discharged patients were readmitted for recurrent pancreatitis prior to their scheduled elective cholecystectomy, and of those, nearly a third recurred within 2 weeks following discharge. Some authors have advocated a very aggressive surgical policytowards early LC in patients with mild gallstone pancreatitis. The most important randomized trial conducted by Abulian et al.  have demonstrated that LC performed within 48 hours of admission, regardless of the resolution of abdominal pain or laboratory abnormalities, results in a shorter hospital length of stay (mean 3,5 days) with no apparent impact on the technical difficulty of the procedure or peri-operative complication rate. This approach was also validated by Rosing  that showed a median length of hospital stay of 4 days in patients who underwent to LC within 48 hours, as compared with a 7-day hospital stay in a retrospective group of 177 patients treated with LC after resolution of abdominal pain and normalizing trend of laboratory enzymes, before implementation of this strategy. The length of hospital stay in the present series was quite longer (8,2 days) this may be related with the heterogeneity of the group of our patients and the non prospective chapter of the study. Moreover this may be cultural with patients expecting to leave hospital only when fully recovered and needing little outpatient care as reported by other Italian studies . However, comparing results of the study presented here with a multicenter Italian work , we have spared 5 days of hospital stay despite the same surgical approach, indicating that, with increasing familiarity with laparoscopy in emergency and with the particular strategy adopted during the study period, we considered early LC in mild ABP the best surgical procedure that can reduce hospitalization without increasing surgical complications related to the inflammation process. Another important issue is patient’s selection for the successful of surgical management of this pathology. Several studies [18,19] have found some predictive factors that should be identify during the early hospitalization course in order to improve the results of early cholecystectomy. We have analyzed our single center’s experience among a big series of 293 patients with mild ABP treated by minimally invasive approach using conventional aparoscopy. In our retrospectiveseries some of patients needed pre-operative fluid resuscitation, respiratory support due to co-morbidities or have developed cardiac complications, leading to a longer hospital stay. Identifying these patients is very useful because they may necessitate other treatments or only conservative management and early treatment should be discouraged.
Patients presenting with mild ABP have a positive predictive value of 2-8% for presence of CBDS . In some studies, in emergency, the clearance of CBDS is generally demanded to a pre-operative ERCP. A Cochrane review and a multicenter randomized trial [21,22] demonstrated that laparoscopic CBDS extraction, when compared with preoperative ERCP, is equivalent in terms of CBDS clearance and morbidity but showed shorter hospital stay. A recent study  has also proved that laparoscopic trans-cystic exploration of the common duct maintains a high yield of success also in acute setting such as acute cholecystitis. As the majority of CBDS pass spontaneously within 48 hours, it is not surprising that a significant rate of unnecessary pre-operative ERCP is reported within literature , highlighting the inaccuracy of current evaluation criteria for persistent CBDS in mild ABP. Hence, a potential drawback of early cholecystectomy strategy is that common duct stones may not be cleared prior to cholecystectomy and those that undergo LC may have higher rates of CBD stones on IOC; so that the single step laparoscopic clearance gain importance in order to not extend days of hospitalization. In the present manuscript 23% of cases have a choledocholithiasis; this rate is higher compared to elective surgery and similar with results showed by other authors that use the early cholecystectomy management for mild ABP [25,26]. Our surgical choice was to perform IOC in mild ABP and to offer these patients a single stage laparoscopic solution of CBDS by using trans-cystic approach as we routinely do in scheduled elective and emergency laparoscopic surgery avoiding pre-operative ERCP. In this surgical scenario, colangio-pancreatic magnetic resonance is unnecessary because patients despite the presence or the absence of signs and symptoms of choledocholithiasis, underwent to IOC and one step approach in case of CBDS. This strategy in mild ABP seems to be very advantageous because we can maximize the pre-operative stay impacting the overall hospitalization also in the presence of CBDS. It was beyond the scope of this study to perform a detailed cost analysis but, based on this finding, it is reasonable to assume that direct and indirect costs were decreased as compared to two step management (ERCP and then surgery). The only indication for urgent pre-operative ERCP should be the presence of severe pancreatitis or concomitant cholangitis.
Trans-cystic approach is easy to perform even by non expert laparoscopic surgeons and several cohort studies [27-29] have shown that more than two thirds of choledochal stones detected by IOC can be removed by this approach. Other techniques like choledochotomy require a high skillfulness in laparoscopic intracorporeal knotting and can be performed only if the common bile duct reaches an adeguate diameter (>1cm). When the LC is performed early and the gallbladder or the common bile duct are nota high skillfulness in laparoscopic intracorporeal knotting and can be performed only if the common bile duct reaches an adeguate diameter (>1cm). When the LC is performed early and the gallbladder or the common bile duct are not involved by the inflammatory process, the identification of the Calot’s structures and the choledochus is not difficult and the laparoscopic CBDS extraction is not more challenging than in elective case. This may be explained by the rate of success of this procedure in our series and in contemporary works . Accordingly, no retained stones were observed during the follow up period. Compared to simple LC, the necessity of CBDS clearance in mild ABP impact the operative time and the post-operative stay that were longer. It’s quite interesting that the conversion rate and morbidity are not different indicating that the additional trauma of single step CBDS clearance is minimal and does not affect the outcome in this situation. In fact reason for conversion and post-operative complications were not directly related with common bile duct exploration but associated to other surgical step of the laparoscopic procedure such as adhesiolisis, dissection of the Calot’s triangle and bleeding from the inflamed tissues. The goal of our strategy is clearing the common bile duct during the same surgical procedure so that when the trans-cystic exploration failed and choledochotomy becomes an utmost challenging procedure, intra-operative ERCP was mandatory. In such instance the possibility of rendez-vous technique with cannulation of the papilla using the guidance of a wire may allow one to avoid specific complications such as pancreatitis, even when patients are in the supine position . Post-cholecystectomy ERCP is the next alternative to a not available or failed intra-operative ERCP; it is considered a failure of single management because it requires patient’ readmission. However also in this case the procedure is facilitated by a guide-wire inserted through the bile drain positioned during the LC. Although some authors [32,33] report the success of leaving untreated some small calculi discovered during IOC, for years we have adopted the policy to remove all ductal stones discovered or confirmed by IOC at the time of LC and we believe that this strategy should be pursued a fortiori when laparoscopy is done for mild ABP.
In conclusion LC can be safely performed in patients with mild ABP during the same admission with acceptable morbidity and mortality rates. A routinary IOC allowed discovering an high incidence of CBDS without false positive images. In the majority of patients was therefore possible to obtain a clearance of CBDS during the same surgical procedure without further procedures and shortening the hospital stay length. After the introduction of LC in clinical practice, laparoscopic management of acute setting like cholecystitis or pancreatitis and laparoscopic exploration of the common bile duct were the two subsequent challenging procedures in the minimally invasive surgery of gallstone disease. As the first became a ‘‘gold standard’’ and the second has gained a wider acceptance, laparoscopic CBD exploration in patients with mild ABP could be the next challenge. Using a early surgical approach in mild ABP, IOC and laparoscopic trans-cystic clearance for CBDS become fundamentals forces that may be to the capacity of every emergency laparoscopic surgeon dealing with this pathology. This management will maximize the reduction in hospitalization.
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