Saudi Journal of Gastroenterology
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Table of Contents   
EDITORIAL  
Year : 2022  |  Volume : 28  |  Issue : 6  |  Page : 401-402
Cholecystectomy for idiopathic acute pancreatitis: Not yet there!


Department of Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana, India

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Date of Web Publication10-Oct-2022
 

How to cite this article:
Jagtap N, Lakhtakia S. Cholecystectomy for idiopathic acute pancreatitis: Not yet there!. Saudi J Gastroenterol 2022;28:401-2

How to cite this URL:
Jagtap N, Lakhtakia S. Cholecystectomy for idiopathic acute pancreatitis: Not yet there!. Saudi J Gastroenterol [serial online] 2022 [cited 2022 Dec 9];28:401-2. Available from: https://www.saudijgastro.com/text.asp?2022/28/6/401/358010

See accompanying article on page 417




Gall stones (GSs) and alcohol are the most common causes of acute pancreatitis (AP).[1] Apart from these pancreato-biliary tumors, endoscopic retrograde cholangiopancreatography, hypertriglyceridemia, hypercalcemia, medication, and autoimmune diseases can also cause AP.[2],[3],[4],[5] Despite exhaustive diagnostic evaluation the cause of AP cannot be determined in about 10–30% of cases, and those are labeled as idiopathic AP.[6],[7] Identifying the etiology is crucial to prevent further episodes of AP. The diagnosis of GS related AP or acute biliary pancreatitis (ABP) is confirmed by the presence of GS along with abnormal liver function tests around the onset of an episode of AP, and/or by demonstrating lithiasis in the bile duct. It is well accepted that patients with ABP should have an early cholecystectomy, preferably in the same admission, to prevent future episodes of AP.

The current retrospective study by Lei and colleagues from China, studied the effect of cholecystectomy on the severity of subsequent attacks of pancreatitis using propensity score matching to correct baseline confounding factors.[8] There were two main observations. First, cholecystectomy reduced the frequency of biliary pancreatitis (30% vs. 46%). Although a known fact, 30% recurrence of ABP after cholecystectomy is still high if the culprit GB has been removed, unless there are remnant biliary calculi or some other cause of ABP, for example, worms moving into the CBD.[9] The second observation is even more striking—there was a lower risk of the severe forms of AP (both moderately severe and severe acute pancreatitis) in patients who had prior cholecystectomy compared to those having intact gallbladder (GB) among the idiopathic acute pancreatitis (IAP) group. This provoking observation indirectly suggests that cholecystectomy is associated with milder severity of acute pancreatitis, if it happens to occur. Can one extrapolate this information and suggest performing cholecystectomy in IAP to prevent future “severe” attacks?

A careful analysis of history and investigations of the presentation of acute pancreatitis helps to identify the etiology. Delving into the available literature, the randomized multicenter trial by Raty, et al.[10] reported that cholecystectomy can prevent the recurrence of IAP and also reduce the number of recurrences. It highlighted that a total of five patients are needed to be treated to prevent one IAP.[10] The meta-analysis from Umans et al.[11] of 524 patients including 10 studies, showed a decreased rate of recurrence after cholecystectomy to 11.1%, compared to 35.2% in the non-cholecystectomy group. da Costa et al.[12] proved the efficacy of cholecystectomy in preventing the recurrence of biliary pancreatitis. All these studies suggest that there is a reduced rate of recurrence of AP after cholecystectomy not only in ABP, but also in a subset of patients labeled IAP. The initially missed diagnosis of inciting GB pathologies like sludge, microliths, or even small stones in the setting of ABP can erroneously be labeled as IAP. The incidence of microlithiasis and sludge in the presence of AP ranges from 28 to 80%.[13] Even the pathological examination of resected GB reports a high rate of microliths.[10],[14] However, one must remember that GB sludge can occur after prolonged fasting in patients with AP, and hence it can be an “effect” and not the cause of AP.

A high-quality endoscopic ultrasound (EUS) of the common bile duct (CBD) after the negative transabdominal ultrasound and biochemical tests, can identify biliary causes of AP. The EUS has higher sensitivity for diagnosing microliths compared to contrast tomography and magnetic resonance cholangiopancreatography.[6],[7] Although EUS is recommended at a later stage in the diagnostic algorithm of idiopathic recurrent acute pancreatitis, it should be considered early in the course of suspected ABP.

Though not routinely performed, bile microscopy is reported to be abnormal in 75% of IAP patients. Patients with abnormal bile microscopy, treated either with cholecystectomy or more conservative endoscopic biliary sphincterotomy, have protection from recurrent attacks of pancreatitis.[14]

To summarize, lack of firm evidence in the causal relationship between cholecystectomy and severity of recurrent attacks of AP, hence surgical removal of GB, cannot be recommended for IAP at this time. Obviously, more data is needed to be collected prospectively from across the globe and scrutinized, including carefully planned randomized controlled studies after negative high-quality EUS examination.



 
   References Top

1.
Mederos MA, Reber HA, Girgis MD. Acute pancreatitis: A review. JAMA 2021;325:382-90.  Back to cited text no. 1
    
2.
Kota SK, Krishna SV, Lakhtakia S, Modi KD. Metabolic pancreatitis: Etiopathogenesis and management. Indian J Endocrinol Metab 2013;17:799-805.  Back to cited text no. 2
    
3.
Aslam M, Talukdar R, Jagtap N, Rao GV, Pradeep R, Rao U, et al. Clinical profile and outcome of parathyroid adenoma-associated pancreatitis. Saudi J Med Med Sci 2018;6:95-9.  Back to cited text no. 3
[PUBMED]  [Full text]  
4.
Nabi Z, Talukdar R, Venkata R, Aslam M, Shava U, Reddy DN. Genetic evaluation of children with idiopathic recurrent acute pancreatitis. Dig Dis Sci 2020;65:3000-5.  Back to cited text no. 4
    
5.
Guda NM, Reddy DN, Kumar A. Complications of ERCP. Indian J Gastroenterol 2014;33:1-9.  Back to cited text no. 5
    
6.
Guda NM, Trikudanathan G, Freeman ML. Idiopathic recurrent acute pancreatitis. Lancet Gastroenterol Hepatol 2018;3:720-8.  Back to cited text no. 6
    
7.
Del Vecchio Blanco G, Gesuale C, Varanese M, Monteleone G, Paoluzi OA. Idiopathic acute pancreatitis: A review on etiology and diagnostic work-up. Clin J Gastroenterol 2019;12:511-24.  Back to cited text no. 7
    
8.
Lei J, Xu F, Cao H, Zhou Z, He S. Cholecystectomy reduces the severity of subsequent idiopathic acute pancreatitis. Saudi J Gastroenterol 2022;28:417-25.  Back to cited text no. 8
[PUBMED]  [Full text]  
9.
Nabi Z, Lakhtakia S, Shava U, Devarasetty R, Reddy DN. Recurrent acute pancreatitis in a toddler: A “wormy surprise”. VideoGIE 2018;3:266-7.  Back to cited text no. 9
    
10.
Raty S, Pulkkinen J, Nordback I, Sand J, Victorzon M, Grönroos J, et al. Can laparoscopic cholecystectomy prevent recurrent idiopathic acute pancreatitis?: A prospective randomized multicenter trial. Ann Surg 2015;262:736-41.  Back to cited text no. 10
    
11.
Umans DS, Hallensleben ND, Verdonk RC, Bouwense SAW, Fockens P, van Santvoort HC, et al. Recurrence of idiopathic acute pancreatitis after cholecystectomy: Systematic review and meta-analysis. Br J Surg 2020;107:191-9.  Back to cited text no. 11
    
12.
da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S, et al. Same-admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): A multicentre randomised controlled trial. Lancet 2015;386:1261-8.  Back to cited text no. 12
    
13.
Wilcox CM, Seay T, Kim H, Varadarajulu S. Prospective endoscopic ultrasound-based approach to the evaluation of idiopathic pancreatitis: Causes, response to therapy, and long-term outcome. Am J Gastroenterol 2016;111:1339-48.  Back to cited text no. 13
    
14.
Saraswat VA, Sharma BC, Agarwal DK, Kumar R, Negi TS, Tandon RK. Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: Response to therapy. J Gastroenterol Hepatol 2004;19:1206-11.  Back to cited text no. 14
    

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Correspondence Address:
Dr. Sundeep Lakhtakia
Director Endoscopy and EUS, Senior Consultant Gastroenterology, Asian Institute of Gastroenterology, Hyderabad, Telangana
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/sjg.sjg_396_22

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