Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections.

The literature regarding patients who sustain an episode of moderate to severe acute pancreatitis primarily focuses on the critical care aspects of management in these patients. As these management principles have been perfected, the survival rates for moderate to severe acute pancreatitis have improved progressively. In gallstone-related acute pancreatitis, cholecystectomy is performed after resolution of the acute event to prevent subsequent episodes. Cholecystectomy is performed during the same hospitalization. Our report focuses on patients who have had moderate to severe acute pancreatitis caused by gallstones. These patients must recover from the acute critical care component of their pancreatitis before undergoing a cholecystectomy. Patients who have recovered from moderate or severe acute pancreatitis uniformly harbor a recognized or at times unrecognized peripancreatic fluid collection.1 Although organized reviews of this issue are scant in the literature, we have become aware of risks arising when these fluid collections are either ignored or poorly managed. The timing of cholecystectomy in patients with peripancreatic fluid collections has not been determined. Early cholecystectomy raises the risk of a second general anesthetic or a risk of a second interventional procedure to manage persistent fluid collections. We additionally have encountered patients with an episode of moderate to severe acute pancreatitis who have had their cholecystectomy and are referred because of an apparent contamination of the peripancreatic fluid collection at time of that operation. These patients may require urgent or emergent management of their peripancreatic fluid collection at a time in which it is still possible that the pseudocyst or fluid collection might have resolved spontaneously had it not been contaminated. In this circumstance, our concern is that early cholecystectomy not only failed to recognize the possibility that the pseudocyst would persist but actually exposed the cyst to contamination and sepsis thus forcing an early intervention in the pseudocyst. It is generally agreed that any patient with an episode of moderate to severe acute pancreatitis should undergo early computed tomographic (CT) imaging. It is our experience that patients will be referred who have not had imaging performed and whose fluid collections simply have never been visualized. In patients whose fluid collections have been visualized, there are times in which a patient’s clinical improvement may be such that a repeat CT scan is not done. We believe patients should have confirmation of resolution of pseudocyst before cholecystectomy for the reasons mentioned. The literature regarding cholecystectomy has addressed a similar issue, the timing of cholecystectomy after severe acute pancreatitis evaluated in a retrospective fashion. These studies have documented that earlier operation for simple acute pancreatitis is safe while early operation after severe acute pancreatitis had an unacceptably high rate of infectious complications.2,3 These studies have not addressed the contribution made by peripancreatic fluid collections. All surgeons essentially agree that gallstone-induced acute pancreatitis has a significant risk of recurrence after the first episode; therefore, prompt operative intervention is the norm.4,5 Naturally, this precept is often violated in patients with moderate to severe acute pancreatitis because so much time is spent in managing the patient’s acute episode. Thus the amount of delay before consideration for cholecystectomy is longer in a patient who has had this magnitude of an attack. Following this standard, a surgeon may feel obligated to proceed promptly to cholecystectomy after the patient has stabilized. We believe that this perceived urgency prompts surgeons and referring physicians to resort to cholecystectomy soon after symptom resolution. We are unaware of any literature regarding the risk of recurrence of acute pancreatitis after moderate to severe gallstone-induced pancreatitis. Several studies have evaluated the evolution of fluid collections after acute pancreatitis. Spontaneous resolution of peripancreatic fluid collections and of pseudocyst has been documented. The frequency with which this may take place is highest in patients whose fluid collection accumulated early after an episode of acute pancreatitis compared with patients with chronic pancreatitis. Some patients never develop a true cyst with resolution of the fluid before a cyst can develop.6–8 Pseudocysts and fluid collections may be treated by percutaneous or endoscopic methods.9–13 The appropriate timing of these techniques has been reviewed carefully.13 These interventions in sterile collections may result in infected peripancreatic fluid collections. The complication of infection in the previously sterile peripancreatic fluid collection may force one to consider definitive operative management of the peripancreatic fluid collection at an earlier stage. In this case, the timing of cholecystectomy is further complicated by prematurely forcing pseudocyst management. It has been our management principle and the basis for our study that patients with moderate to severe acute pancreatitis and documented fluid collections be given a period of evaluation that takes place after the medical stabilization of their episode. Once the pseudocyst is found to resolve, then cholecystectomy is undertaken. If the pseudocyst persists, combined management of the gallbladder and the pseudocyst is performed simultaneously. We have been interested over the years in assessing the behavior of pseudocyst and the influence that ductal anatomy may play in the behavior of pseudocyst. This information has been specifically applied to the successes of nonoperative measures such as percutaneous drainage in treating pseudocysts.14,15 As we have followed the current group of patients, we have examined ductal anatomy in those patients whose cysts persist. We are interested in the possibility that ductal anatomy may well predict those patients who have persistence of pseudocyst.