In cases of gallstones and pancreatitis, should gastroenterology (GI) or surgery be involved?

Management of Gallstones and Pancreatitis: Gastroenterology vs. Surgery Involvement

In cases of gallstones and pancreatitis, a multidisciplinary approach involving both gastroenterology and surgery is recommended, with the specific timing and sequence determined by disease severity and clinical presentation. 1

Initial Management Based on Disease Severity

Mild Gallstone Pancreatitis

• Laparoscopic cholecystectomy by surgery during index admission is strongly recommended (Grade 1A recommendation) 1
• Cholecystectomy should be performed as soon as the patient has recovered, preferably during the same hospital admission to prevent recurrent pancreatitis 1, 2
• Surgery should ideally be performed within 2 weeks and no longer than 4 weeks after presentation 2

Severe Gallstone Pancreatitis

• Initial management should be in an HDU or ITU setting with full monitoring and systems support 1
• Gastroenterology involvement is critical for urgent ERCP in specific scenarios:
  • Failure to improve within 48 hours despite intensive resuscitation 1
  • Increasingly deranged liver function tests and signs of cholangitis (fever, rigors, positive blood cultures) 1
• Surgical cholecystectomy should be delayed until the inflammatory process has subsided 1, 2

Specific Indications for ERCP (Gastroenterology)

• Urgent ERCP with sphincterotomy is indicated in:
  • Severe gallstone pancreatitis with biliary obstruction 1
  • Cholangitis 1
  • Persistent common bile duct stones 1, 2
• ERCP should always be performed under antibiotic cover 1
• Facilities and expertise should be available to perform ERCP at any time for common bile duct evaluation followed by sphincterotomy and stone extraction or stenting as required (Grade A recommendation) 1

Timing of Cholecystectomy (Surgery)

• For mild gallstone pancreatitis: Perform cholecystectomy during the same hospital admission 1, 2
• For severe gallstone pancreatitis: Defer cholecystectomy until inflammation subsides 2
• When peripancreatic fluid collections are present: Defer cholecystectomy until fluid collections resolve or stabilize (Grade 2C recommendation) 1
• If local complications develop (pseudocyst, infected necrosis): Perform cholecystectomy when complications are treated surgically or have resolved 1

Special Considerations

When Both ERCP and Cholecystectomy Are Needed

• When ERCP and sphincterotomy are performed during the index admission, same-admission cholecystectomy is still advised due to increased risk for other biliary complications (Grade 1B recommendation) 1
• ERCP reduces the risk of recurrent pancreatitis but does not eliminate the risk of other biliary complications 2

Necrotizing Pancreatitis

• A local multidisciplinary group of experts should individualize the surgical strategy 1
• Minimally invasive strategies (step-up approach, video-assisted retroperitoneal debridement, or endoscopic approaches) result in less new-onset organ failure but require more interventions 1
• For infected necrosis, surgical debridement should be performed when the patient is clinically stable 3

Common Pitfalls to Avoid

• Delaying cholecystectomy beyond 2-4 weeks in mild gallstone pancreatitis increases the risk of recurrent biliary events 2
• Performing early cholecystectomy in patients with peripancreatic fluid collections can lead to more complications 1
• Failure to recognize the need for urgent ERCP in patients with cholangitis or persistent biliary obstruction 1
• Over-resuscitation in early severe acute pancreatitis can worsen outcomes; intra-abdominal pressure should be measured regularly 1

Conclusion

The optimal management of gallstone pancreatitis requires close collaboration between gastroenterology and surgery. Gastroenterology is primarily involved for ERCP in specific indications, while surgery is needed for definitive management through cholecystectomy. The timing of these interventions depends on disease severity, with early cholecystectomy recommended for mild disease and delayed intervention for severe cases or those with complications.