Management of Acute Biliary Pancreatitis in Cholecystectomized Patients

Objective: We aimed to evaluate the patients who were hospitalized, followed up and treated in our clinic with the diagnosis of acute biliary pancreatitis (ABP) after cholecystectomy. Methods: The electronic records of 18 patients with a history of cholecystectomy were reviewed retrospectively. The demographic findings of the patients, time passed after cholecystectomy, methods used in diagnosis, amylase levels, treatment choices, clinical follow-ups, mortality and morbidity rates, and length of hospital stay were evaluated. The Ranson criteria and Apache II score were used to determine the severity of pancreatitis. Results: Thirteen (72.2%) were female and 5 (27.8%) were male. The mean age was 57.83±12.59 (34-77). The mean time elapsed after cholecystectomy was 72.11±38.12 (5-130) months. The mean diameter of the common bile duct (CBD) was measured as 12.39±2.30 (8-15) mm. The average level of amylase was 986.50±323.29 (350-1530) U/L. Fifteen (83.33%) patients had mild, and 3 (16.67%) patients had moderately severe acute biliary pancreatitis. Endoscopic sphincterotomy (ES) was performed on 16 patients during endoscopic retrograde cholangiopancreatography (ERCP). Two patients were operated due to failure of ERCP. Choledochotomy, transduodenal sphincteroplasty and The T-tube drainage were performed on 1 patient. The other underwent choledochotomy and choledochoduodenostomy. The average length of stay in hospital was 7.89±4.91 (5-25) days. (5-130) months. The rate of incidence of patients with cholecystectomy in the etiology of ABP was found to be 3.08%. Intravenous contrast-enhanced abdominal tomography (CT) was performed on all patients to evaluate the pancreas. CT was repeated 48 and 96 hours later when patients’ clinical conditions had not changed. MRCP was performed on all patients to show the CBD diameter and the presence of stones. The mean diameter of the CBD was measured as 12.39±2.30 (8-15) mm by MRCP. The average level of amylase was 986.50±323.29 (350-1530) U/L. Fifteen (83.33%) patients had mild, and 3 (16.67%) patients had moderately severe ABP according to the Ranson’s criteria and Apache II score. None of the patients had severe ABP. Patients with moderately severe ABP responded to medical therapy. None of the patients needed intensive care unit. All patients underwent endoscopic retrograde ERCP. ES was performed on 16 of the 18 patients during ERCP. Two patients were operated due to failure of ERCP. CBD exploration was performed on both patients surgically. Four to five stones were removed from the CBD in one patient. The transition from CBD to duodenum was controlled with dilators. Transduodenal sphincteroplasty was performed because there was stenosis in the Oddi sphincter. A T-tube was inserted into the CBD. T-tube cholangiography was executed on the 14 th day. The T-tube was removed since no pathology was found in the for acute pancreatitis caused by CBD stones in patients with cholecystectomy are ERCP and ES. In patients with failed ERCP and ES, the CBD exploration should be performed surgically.