Yusuf YAĞMUR, Akın ÖNDER, Murat KAPAN, Ünal BEYAZIT, Metehan GÜMÜŞ

Akut biliyer pankreatitli hastalarda erken laparoskopik kolesistektomi sonuçları

Amaç: Akut biliyer pankreatit (ABP) tedavisinde erken dönemde yapışıklıklar ve diseksiyon güçlüğü nedeniyle laparoskopik kolesistektomi (LK) uygulaması tartışmalıdır. Bu çalışmanın amacı, ABP tanısı ile kliniğimizde yatırılan ve taburcu edilmeden önce LK yapılan 43 hastanın sonuçlarını değerlendirmektir. Yöntemler: Eylül 2006 – Mart 2009 tarihleri arasında ABP tanısıyla tedavi edilen, klinik ve laboratuar bulguları düzeldikten sonra LK uygulanan 43 hasta geriye dönük olarak incelendi. Hastaların yaş, cinsiyet, laboratuar bulguları, ultrasonografi (USG), manyetik rezonans kolanjiyopankreotografi (MRKP) ve endoskopik retrograd-kolanjiyopankreotografi (ERKP) sonuçları, yapılan ameliyat, ameliyat süreleri, açık ameliyata geçme oranları, gelişen komplikasyonlar, mortalite ve hastanede yatış süreleri kaydedilerek istatistiksel analiz uygulandı. Bulgular: Hastaların ortanca yaşı 51.8 (20-83) yıl olup; 29'u (%67.4) kadın, 14'ü (%32.6) erkekti. Hastaların tamamında akut pankreatit nedeni safra taşlarıydı. Ek olarak bir hastada hiperparatiroidi, diğer birinde hiperlipidemi mevcuttu. Hastaların tamamında USG’de safra kesesinde taş saptanmıştı. İntrahepatik safra yolları ve koledokta genişleme saptanan 7 hastaya yapılan MRKP’de koledokta taş tespit edildi. Bu hastalardan 3’ünde klinik ve laboratuar bulgularında düzelme sağlanamaması nedeniyle ERKP ile sfinkterotomi ve taş ekstraksiyonu yapıldı. Hastalarımıza ortalama 11.4’üncü günde (3.–23. günlerde) operasyon uygulandı. Toplam olarak 39 (%90.6) hastaya LK uygulanırken, 4 (%9.4) hastada enfeksiyona sekonder intraabdominal yapışıklıklar ve diseksiyon güçlüğü nedeniyle açık ameliyata geçildi. Ortalama ameliyat süresi 70 (25-160) dakika olarak bulundu. Postoperatif ortalama yatış süresi 3 (1-6) gündü. LK uygulanan ve operasyon öncesi ERKP yapılan bir hastada (%2.3) komplikasyon gelişti. Bu hastada, postoperatif 3. gün nekrotizan pankreatit gelişmesi üzerine ikinci operasyona alınarak drenaj uygulandı. Erişkin tip solunum sıkıntısı sendromu gelişen bu hasta postoperatif 7. günde kaybedildi.Sonuç: Klinik ve laboratuar olarak iyileşen ABP'li hastalarda, ilk yatışta uygulanan geç LK güvenli bir cerrahi tedavi seçeneği olabilir.

The outcome of early laparoscopic cholecystectomy in patients with acute biliary pancreatitis

Objectives: It is still controversial to perform a laparoscopic cholecystectomy (LC) for the management of acute biliary pancreatitis (ABP) at the early hospitalization period, because of adhesions and dissection difficulties. The aim of this study was to evaluate the outcome of the patients with ABP who underwent LC prior to hospital discharge. Methods: A total of 43 patients with ABP, that underwent LC after clinical and laboratory improvement, were retrospectively evaluated. Patient’s age, gender, laboratory findings; ultrasonography (USG), magnetic resonance and other imaging results, surgical operation duration,complications, mortality and postoperative hospital stay days were recorded and statistically analyzed.Results: The median age of patients was 51.8 (20-83) years. A total of 29 (67.4%) patients were women and 14 (32.6%) were male. The cause was gallstone in all patients. In addition, hyperparathyroidism was found in one patient and hyperlipidemia was present in the other one. Gallbladder stones were determined in all patients. Common bile duct enlargement and stones were detected in 7 patients. Three patients underwent sphyncterectomy and stone extraction according to clinical status. Operations were performed at the mean hospitalization day of 11.4 (3-23). LC was performed to 39 (%90.6) of patients. However, 4 (9.4%) patients had intra-abdominal adhesions secondary to infection and were switched to open surgery. The mean operation time was 70 (25-160) minutes and the mean duration of postoperative hospital stay was 3 (1-6) days. In a patient who underwent LC and ERCP preoperatively complication occurred. A second drainage operation was performed and due to development of necrotizing pancreatitis, the patient was lost at the postoperative 7th day secondary to adult type respiratory distress syndrome. Conclusions: In patients with ABP whose clinical and laboratory findings were improved, late LC can be performed safely during their first hospitalization.

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1. Bradley III EL. A clinically based classification system for acute pancreatitis. Summary of the International Symposium on Acute Pancreatitis, Atlanta, GA, September 11 through 13, 1992. Arch Surg 1993;128:586-90.
2. Lankisch PG, Burchard-Reckert S, Lehnick D. Underestimation of acute pancreatitis: patients with only a small increase in amylase/lipase levels can also have or develop severe acute pancreatitis. Gut 1999;44:542-4.
3. Byrne MF, Mitchell RM, Stiffler H, et al. Extensive investigation of patients with mild elevations of serum amylase and/or lipase is low yield. Can J Gastroenterol 2002;16:849-54.
4. Wong EC, Butch AW, Rosenblum JL. The clinical chemistry laboratory and acute pancreatitis. Clin Chem 1993;39:234-43.
5. Koizumi M, Takada T, Kawarada Y, et al. JPN Guidelines for the management of acute pancreatitis: diagnostic criteria for acute pancreatitis. J Hepatobiliary Pancreat Surg 2006;13:25-32.
6. Ranson JHC. The timing of biliary surgery in acute pancreatitis. Ann Surg 1979; 189:654-62.
7. Salman B, Yüksel O, Irkörücü N, et al. Urgent laparoscopic cholecystctomy is the best management for biliary colic. Dig Surg 2005;22:95-9.
8. Kaw M, Al-Antably Y, Kaw P. Management of gallstone pancreatitis: cholecystectomy or ERCP and endoscopic sphincterotomy. Gastrointestinal Endoscopy 2002;56:61-5.
9. Tang E, Stain SC, Tang G, Froes E, Berne TV. Timing of laparoscopic surgery ingallstone pancreatitis. Arch Surg 1995;130:496-9.
10. Alimoglu O, Ozkan OV, Şahin M, Akçakaya A, Eryılmaz R, Baş G. Timing of Cholecystectomy for Acute Biliary Pancreatitis: Outcomes of Cholecystectomy on First Admission and after Recurrent Biliary Pancreatitis. World J. Surg 2003;27:256-9.
11. Sinha R Early laparoscopic cholecystectomy in acute biliary pancreatitis: the optimal choice? HPB 2008;10:332-5
12. Srinathan SK, Barkun JS, Mehta SN, Meakins JL, Barkun AN. Evolving management of mild-to-moderate gallstone pancreatitis. J Gastrointest Surg 1998;2:385-90.
13. Senapati PS, Bhattarcharya D, Harinath G, Ammori BJ. A survey of the timing and approach to the surgical management of cholelithiasis in patients with acute biliary pancreatitis and acute cholecystitis in the UK. Ann R Coll Surg Engl 2003;85:306-12
14. Uhl W, Müller CA, Krahenbühl L, Schmid SW, Schölzel S, Büchler MW. Timing of laparoscopic cholecystectomy in mild and severe disease. Department of Visceral and Transplantation Surgery, University Hospital of Bern. Surg Endosc 1999;13:1070-6
15. Taylor E, Wong C. The optimal timing of laparoscopic cholecystectomy in mild gallstone pancreatitis. Ann Surg 2004;70:971-5.