Читать книгу Clinical Pancreatology for Practising Gastroenterologists and Surgeons - Группа авторов - Страница 164

The main challenge in cases of ABP without ongoing biliary obstruction remains to identify those patients with retained CBD stones who are clear candidates for elective ERCP after resolution of the initial attack. Abdominal ultrasound and computed tomography (CT) are the most commonly used diagnostic modalities in the setting of ABP, but their diagnostic accuracy in detecting CBD stones is limited, which is particularly relevant in the case of false‐negative results [25]. Traditionally, ERCP is considered the gold standard for diagnosing CBD stones, but its diagnostic capabilities have to be balanced against the non‐negligible rate of procedure‐related adverse events. The emergence of novel imaging methods, such as magnetic resonance cholangiopancreatography (MRCP) and EUS, have almost obviated the need for diagnostic ERCP in the case of CBD stones. Recent data suggests that MRCP performed on the seventh day after an initial episode of APB has a high positive predictive value (>93%) in detecting persistent CBD stones [4]. EUS has also been shown to have high accuracy in detecting CBD stones, which is especially useful for avoiding unnecessary ERCP in patients with intermediate risk of CBD stones [26]. Actually, EUS shows higher sensitivity than endoscopic cholangiography alone, probably because radiological evaluation during ERCP can miss diminutive stones that can easily be demonstrated on EUS. EUS is also more sensitive than MRCP in detecting small stones (<5 mm) [27]. When considering an elective intervention for clearance of retained CBD stones, the physician should take into account the patient’s condition (i.e. ongoing local or systemic complications of the initial episode of ABP) and the need for additional interventions such as cholecystectomy or pseudocyst drainage. Decisions regarding the timing of ERCP in this setting are usually made by a multidisciplinary team, on a case‐by‐case basis, with no clear‐cut guidelines available for most clinical situations, especially in the case of patients recovering from severe attacks of pancreatitis [28]. The AGA currently recommends index cholecystectomy as standard of care for all patients with ABP who are deemed fit for surgery [1]. Concomitant gallstones and CBD stones can be managed by a variety of strategies including preoperative, intraoperative or postoperative ERCP as well as laparoscopy‐assisted CBD exploration which obviates the need for ERCP. In the absence of evidence‐based data to clearly favor one approach over another [29], the main factors in choosing either one of these strategies is usually the infrastructure and expertise available in each center. In the particular case of APB patients showing both gallbladder and CBD stones, there is evidence supporting both a combined surgical and endoscopic intervention at index admission [30] as well as a two‐step strategy, with ERCP at index admission followed by cholecystectomy at a later date [31]. Except for the case of severely ill patients, it seems reasonable to consider ERCP plus sphincterotomy at index admission to avoid recurrent attacks of APB [30].

Figure 13.2 Role of endoscopic therapy in the setting of acute biliary pancreatitis. See text for abbreviations.