Safe laparoendoscopic approach to biliary pancreatitis in older patients.
OBJECTIVE
To evaluate management strategies for biliary pancreatitis in different age groups.


METHODS
Retrospective review.


METHODS
Large private metropolitan teaching hospital.


METHODS
Patients seen between January 1991 and December 1994 with a diagnosis of biliary pancreatitis (N = 136) divided into 2 groups (group 1, aged < 65 years; group 2, aged > or = 65 years).


METHODS
Primary treatments included endoscopic retrograde cholangiography (n = 36) alone or with endoscopic sphincterotomy (n = 27); operative procedures, including cholecystectomy by laparoscopic (n = 54) or open (n = 16) approaches; or no definitive therapy (n = 22). Secondary treatments of common bile duct stones included laparoscopic transcystic bile duct exploration (n = 5), open common bile duct exploration (n = 4), or postoperative endoscopic retrograde cholangiography (n = 10).


METHODS
Success of interventions, incidence and treatment of common bile duct stones, morbidity and mortality rates, frequency of retained stones, and length of hospitalization.


RESULTS
Numbers of Ranson criteria were higher for older patients (group 1, 0.83 +/- 0.12 vs group 2, 1.57 +/- 0.11 [mean +/- SEM]; P < .001). Primary endoscopic retrograde cholangiography with or without endoscopic sphincterotomy was performed earlier than operative procedures, with a significantly higher incidence of common bile duct stones (72% vs 19%; P < .001). Number of primary procedures and complication and mortality rates for endoscopic retrograde cholangiography with or without endoscopic sphincterotomy were 36, 8%, and 3%, respectively; for laparoscopic cholecystectomy, 54, 9%, and 2%, respectively; and for open cholecystectomy, 16, 6%, and 19%, respectively. For complication and mortality rates, there were no statistical differences between groups or among treatments. Deferred therapy was used in 30 patients, with 20% readmitted for recurrence of biliary pancreatitis. Length of intensive care unit and total hospital stay were similar for all groups and treatments.


CONCLUSIONS
Older patients with biliary pancreatitis may be safely treated with a combined laparoendoscopic approach. Management of common bile duct stones depends on age, with laparoscopic transcystic duct exploration or open common bile duct exploration preferred for younger patients and laparoscopic transcystic duct exploration or postoperative endoscopic sphincterotomy for older ones. Deferred therapy has a substantial relapse rate.
McGrath
M F
MF
Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, USA.
McGrath
J C
JC
Gabbay
J
J
Phillips
E H
EH
Hiatt
J R
JR
D000293:Adolescent; D000328:Adult; D000367:Age Factors; D000368:Aged; D000369:Aged, 80 and over; D000465:Algorithms; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000009:adverse effects / Q000379:methods*; D017081:Cholecystectomy, Laparoscopic / Q000009:adverse effects / Q000379:methods*; D005260:Female; D042882:Gallstones / Q000150:complications*; D006801:Humans; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000209:etiology / Q000601:surgery*; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects / Q000379:methods*; D016896:Treatment Outcome