What is the indication for surgery with cholelithiasis (gallstones) and elevated lipase levels, indicating hyperlipasemia (elevated lipase)?

From the Guidelines

Surgery is indicated for gallstones with elevated lipase when there is evidence of gallstone pancreatitis, which occurs when a gallstone temporarily blocks the pancreatic duct, causing inflammation of the pancreas. The standard treatment is laparoscopic cholecystectomy (surgical removal of the gallbladder), typically performed after the acute pancreatitis has resolved, usually within the same hospitalization or within 2-4 weeks of the initial attack 1. Early surgery (within 48-72 hours of admission) may be appropriate for mild cases with improving symptoms, while more severe cases require supportive care first with IV fluids, pain management, and bowel rest until inflammation subsides. Some key points to consider in the management of gallstone pancreatitis include:

• Urgent ERCP (Endoscopic Retrograde Cholangiopancreatography) with sphincterotomy may be necessary if there is evidence of ongoing biliary obstruction, cholangitis, or worsening pancreatitis 1.
• Delaying cholecystectomy increases the risk of recurrent pancreatitis, which occurs in approximately 30-50% of untreated patients.
• The combination of gallstones and elevated lipase strongly suggests a gallstone-mediated pancreatic process that requires definitive surgical management to prevent recurrence. Recent guidelines from the World Society of Emergency Surgery also support surgery as the gold standard treatment for acute calculus cholecystitis, with the exception of patients who refuse surgery or are at very high risk for surgery 1. However, the management of high-risk patients with acute calculus cholecystitis is still a topic of debate, and more research is needed to determine the best approach for these patients. In general, the decision to perform surgery should be based on the individual patient's risk factors, overall health, and the severity of their symptoms. Some benefits of surgery include:
• Reduced risk of recurrent pancreatitis
• Improved quality of life
• Reduced risk of complications, such as cholangitis or bile duct obstruction On the other hand, some potential drawbacks of surgery include:
• Risks associated with anesthesia and surgery, such as bleeding or infection
• Potential for bile duct injury
• Need for hospitalization and recovery time. Overall, the decision to perform surgery should be made on a case-by-case basis, taking into account the individual patient's needs and circumstances.

From the Research

Indications for Surgery with Cholelithiasis and Elevated Lipase Levels

The indication for surgery with cholelithiasis (gallstones) and elevated lipase levels, indicating hyperlipasemia (elevated lipase), is primarily based on the severity of the acute pancreatitis and the presence of complications such as cholangitis or biliary obstruction.

• Patients with mild acute pancreatitis can undergo same-admission cholecystectomy, with early cholecystectomy within 48 hours of admission being supported by several randomized clinical trials 2.
• For patients with severe or moderately severe disease, the optimal timing of cholecystectomy remains unclear, and it is often delayed until the patient's condition improves 2.
• Preoperative endoscopic retrograde cholangiopancreatography (ERCP) is generally only recommended for patients with suspected cholangitis or biliary obstruction 2, 3.
• The management of gallstone pancreatitis is dependent on the severity of the disease and the presence of concomitant biliary diagnoses, with goal-directed, moderate fluid resuscitation being a key component of treatment 2.

Role of ERCP in Gallstone Pancreatitis

The role of ERCP in the management of gallstone pancreatitis is limited to patients with suspected cholangitis or biliary obstruction.

• A meta-analysis found that acute ERCP in patients with gallstone-induced acute pancreatitis does not reduce the risk of complications, and therefore ERCP should not be used routinely in these patients 4.
• However, early routine ERCP may be beneficial in patients with cholangitis or biliary obstruction, with a significant reduction in mortality and local and systemic complications observed in these patients 5.

Timing of Cholecystectomy

The timing of cholecystectomy in patients with gallstone pancreatitis depends on the severity of the disease.

• Patients with mild disease can undergo same-admission cholecystectomy, while those with severe or moderately severe disease may require delayed cholecystectomy until their condition improves 2, 3.
• Index cholecystectomy is safe and recommended, except in cases with significant local and systemic complications where delayed cholecystectomy may be safer 3.