Pancreatiti acute biliari



Ann. Ital. Chir., LXIX, 6, 1998

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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 trancystic 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 ERCPES
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 debridment associated with continous local
lavage of the lesser sac) is recommended, while less frequently
ventral open packing should be required.


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