LAUSR

Though acute gallstone pancreatitis, a serious complication of gallstone disease accounting for 40–60% of cases of acute pancreatitis in some populations, is associated with significant morbidity and mortality [1], only 3–7% of patients with gallstones develop pancreatitis. Since a common biliary and pancreatic channel entering the ampulla of Vater frequently exists, acute pancreatitis is often triggered when a migrating gallstone obstructs the pancreatic duct [2]. Acute gallstone pancreatitis is often caused by small stones (< 5 mm in diameter) and by biliary sludge and microlithiasis [3] since these small or microscopic stones are more likely than large stones to pass through the cystic duct and obstruct the ampulla. Since cholelithiasis is more prevalent in women than in men, gallstone pancreatitis is more common in females [3]. Gallstone pancreatitis is due to a migrating stone that obstructs the pancreatic duct by impacting in the distal bile duct, thereby increasing pressure in the pancreatic ducts, eventually damaging ductal and acinar cells. Severe pancreatitis often causes local inflammatory complications, a systemic inflammatory response, and even sepsis. Animal experiments have revealed that ligation of the pancreatic duct causes severe necrotizing pancreatitis and that decompression of the ductal system within three days prevents progression to acinar cell necrosis and severe inflammation. Cholecystectomy and choledocholithotomy prevent recurrence in patients with gallstone pancreatitis, confirming the cause-and-effect relationship [4, 5]. Cholecystectomy is routinely performed in patients with gallstone pancreatitis; if common bile duct (CBD) stones exist, choledocholithotomy should also be carried out [4, 5]. Furthermore, surgery should be performed as soon as the acute inflammatory process has subsided and the patient has recovered. A second potential indication for surgery in severe pancreatitis is debridement of pancreatic necrosis, i.e., necrosectomy, or drainage of a pancreatic abscess. Nevertheless, surgery for severely infected pancreatic necrosis is associated with a mortality rate of 15–75%, especially within the first few weeks of the attack in high-risk patients and in the elderly. Delaying surgery beyond the fourth week in patients with severe necrotizing pancreatitis is associated with a lower mortality rate. Furthermore, gallstone removal and biliary decompression can prevent the recurrence of acute gallstone pancreatitis and pancreatitis-related complications. As a result, urgent (within 24 h of admission) endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) have been widely accepted as the initial treatment of choice [4, 5]. Though endoscopic treatment is especially favored in elderly patients due to the high morbidity and mortality associated with surgical interventions, delayed surgery increases the risk of recurrence of gallstone pancreatitis with consequent increased risk of mortality. Moreover, the multiple episodes of gallstone migration observed in numerous patients implies that repeated passage of gallstones is very likely to be responsible for the * David Q.-H. Wang [email protected]