[Acute biliary pancreatitis]

Biliary pancreatitis is a major complication of gallstones (6-8%) and mainly affects patients with microlithiasis (22%) and cholesterolosis (29%) of the gallbladder. Transient or prolonged obstruction of the ampulla represents the accepted cause and severe forms of acute pancreatitis are more frequently associated with microlithiasis (21.3% vs. 9.6%) with higher incidence of mortality (6.5% vs. 3.2%) as compared with patients with cholelithiasis. The treatment of cholelithiasis and choledocholithiasis performed electively during the same admission, after manifestations of acute pancreatitis had subsided, is an effective procedure to prevent the development of recurrent attacks of pancreatitis. Removal of the gallbladder alone in most patients may represent the definitive treatment, most common bile duct stones passing spontaneously through the papilla during the first four days after admission. Laparoscopic cholecystectomy has gained wide acceptance in the treatment of cholelithiasis, but the management of associated choledocholithiasis results still undefined. Personal strategy is to adopt a more selective approach during the acute attack, limiting the performance of ERCP-ES within the first 48 hours to those patients presenting with laboratory and clinical evidence of ampullary obstruction. If choledocholithiasis is found during laparoscopic cholecystectomy, personal recommendation is to attempt the transcystic removal of stones; if this is not feasible, a conversion of the laparoscopic procedure to an open common bile dut exploration should be carried out. Postoperative ERCP-ES does not seem a reasonably strategy, while preoperative ERCP-ES with gallbladder left in situ as treatment alone of associated biliary tract lesions may be considered in high risk patients. The surgical treatment of pancreatic lesions should be reserved to those patients with extended and unmarked or infected pancreatic necrosis, and pancreatic abscess. Closed management (surgical debridement associated with continuous local lavage of the lesser sac) is recommended, while less frequently ventral open packing should be required.