Introduction

Acute biliary pancreatitis in pregnant patients poses a rare yet significant challenge for clinicians. While early cholecystectomy is a recommended approach after mild biliary pancreatitis in the general population to prevent recurrence and mitigate gallstone-related complications, specific guidelines for managing acute pancreatitis (AP) in pregnant patients are lacking.

Aims & Methods

This study aimed to investigate the safety and effectiveness of cholecystectomy during pregnancy following an episode of mild acute biliary pancreatitis. An international survey was conducted across seventeen centers worldwide in 2023, using both Excel and Redcap platforms. The survey encompassed questions related to demographic information, clinical presentation, management strategies, timing of cholecystectomy, approaches to the procedure, complications, and outcomes (including recurrence of AP, other gallstone-related complications, and maternal and fetal outcomes). Descriptive statistics were calculated for continuous variables, while categorical values were represented as case numbers and percentages. Statistical significance was determined using a t-test and the Mann–Whitney U and Mood’s test.

Results

The study included pregnant women who underwent cholecystectomy during or after pregnancy. According to our international survey, 22% (11/50) of patients had cholecystectomy during pregnancy. Patients who underwent cholecystectomy had a lower rate of readmission due to recurrent AP episodes or other gallstone-related complications (0% and 28%; 0/11 and 11/39). There were no significant differences in cholecystectomy-related complications (9.1% and 12%; 1/11 and 3/26). The incidence of preterm birth was 11% and 8.1% (1/9 and 3/37), while fetal loss rates were 18% (2/11) both fetal losses occurred when surgery was performed in the first trimester and 0% (0/39).

Conclusion

Cholecystectomy effectively prevents the recurrence of AP and other biliary complications, with no observed differences in intra- and postoperative complications during and after pregnancy. Thus, cholecystectomy should be performed in mild biliary pancreatitis in the second and third trimesters of pregnancy. Further studies are needed to evaluate the safety of cholecystectomy in the first trimester.

Introduction

Acute biliary pancreatitis in pregnant patients is a low-prevalence, challenging clinical situation. The current guidelines for acute pancreatitis (AP) in the general population have no specific recommendations for managing it in pregnant patients.

Aims & Methods

This study investigated the safety and effectiveness of cholecystectomy during pregnancy in AP.
This international multicentre cohort study was endorsed and announced by the four major pancreatic societies (International Association of Pancreatology [IAP], American Pancreatic Association [APA], European Pancreatic Club [EPC], and Japan Pancreas Society [JPS]). The survey encompassed questions related to demographic information, clinical presentation, management strategies, timing of cholecystectomy, approaches to the procedure, complications, and outcomes (including recurrence of AP, other gallstone-related complications, and maternal and fetal outcomes). The data were summarized as medians and interquartile ranges for continuous variables and frequencies with percentages for categorical variables, with group comparisons performed using Welch's t-test and Pearson's chi-squared or Fisher's exact tests.

Results

116 cases from 15 countries and 20 centres were enrolled. Cholecystectomy after mild AP during pregnancy had a lower rate of readmission due to recurrent AP episodes or other gallstone-related complications compared to those who did not undergo surgery after a mild AP during pregnancy (0% vs 27%; 0/17 vs 14/51, p=0.015). Cholecystectomy performed during pregnancy was associated with a low surgical complication rate, identical to that seen in postpartum procedures (12% vs 10%; 2/17 vs 3/31; p>0.999). Preterm birth occurred in 7.1% (1/14) vs. 11% (5/45) of patients with and without cholecystectomy during pregnancy, respectively. Fetal loss after surgery occurred only in the first trimester (3/17 vs 1/51).

Conclusion

Cholecystectomy is an effective and safe intervention in pregnant patients during the second or third trimester in cases of mild biliary pancreatitis.

Disclosure

None to declare.

Introduction

Acute pancreatitis (AP) during pregnancy is a rare but potentially life-threatening condition for both mother and fetus. The most common cause is gallstone disease, followed by hypertriglyceridemia and, less frequently, alcohol use. The physiological changes of pregnancy can mask the clinical presentation, delaying diagnosis and intervention. This review aims to synthesize current evidence on the diagnosis, management, and maternal-fetal outcomes of AP in pregnancy, with special attention to the role and timing of cholecystectomy during an acute episode.

Aims & Methods

A comprehensive literature search was conducted using PubMed, Scopus, and the Cochrane Library for studies published between 2000 and 2024. Inclusion criteria involved clinical trials, cohort studies, systematic reviews, and relevant guidelines discussing AP in pregnancy and cholecystectomy

Results

​The majority of AP cases in pregnancy occur in the third trimester or early postpartum period. Gallstones account for 65–100% of cases. Conservative management remains the first-line approach, particularly in the first trimester. However, recurrence rates up to 70% with conservative therapy alone have prompted a reevaluation of surgical timing. Recent studies support the safety of cholecystectomy during the second trimester and even during stabilized mild to moderate AP. In the third trimester, ERCP with endoscopic biliary sphincterotomy is preferred, with cholecystectomy deferred postpartum. Multidisciplinary management has significantly improved maternal and neonatal outcomes in recent years.

Conclusion

Acute pancreatitis in pregnancy remains a rare but serious condition requiring timely diagnosis and multidisciplinary care. Recent innovations support the safety and efficacy of cholecystectomy laparascopyce during the second trimester and even in selected stabilized cases of mild acute pancreatitis. Personalized management strategies based on gestational age and disease severity, along with minimally invasive techniques like ERCP, offer improved maternal and fetal outcomes.
Laparascopi Colecystectomy prevens the recurrent acute pancreatitis and other complications billiaris.
No differenc in the intra and postoperative complications during and after pregnancy.

References

1. Forsmark CE, Vege SS, Wilcox CM. Acute pancreatitis. N Engl J Med. 2016;375(20):1972–81.
2. Tenner S, Baillie J, DeWitt J, Vege SS. American College of Gastroenterology guideline: management of acute pancreatitis. Am J Gastroenterol. 2013;108(9):1400–15.
3. Yokoe M, Takada T, Mayumi T, et al. Japanese guidelines for the management of acute pancreatitis: JPN Guidelines 2015. J Hepatobiliary Pancreat Sci. 2
4. Rosing DK, de Virgilio C. Early cholecystectomy for mild gallstone pancreatitis: time for a paradigm shift
   

Disclosure

Taibe Haziri
*University Clinical Center University of Kosovo*

Introduction

Cholecystectomy is recommended for patients with acute biliary pancreatitis to prevent recurrence and other biliary complications. However, some patients, due to advanced age and comorbidities, are unfit for surgery. The role of endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) in these cases is not well established^1,2.

Aims & Methods

We aimed to evaluate whether ES reduces the risk of recurrent biliary pancreatitis (RBP) in patients unfit for cholecystectomy.
A unicentric retrospective review was conducted including all patients admitted for a first episode of acute biliary pancreatitis between January 2016 and November 2023 at a non-tertiary hospital, who were deemed unfit for cholecystectomy by either surgical or anesthetic teams. Patients with concurrent acute cholangitis at admission or during hospitalization, as well as those with prior cholecystectomy or ES, were excluded. Time-to-event analysis was performed using Kaplan-Meier survival curves.

Results

A total of 169 patients were included, with a mean age of 79.07 ± 8.25 years, and 65% were female. The mean Charlson Comorbidity Index was 5.11 ± 2.09. Most cases (94%) presented as mild or moderately severe pancreatitis. The mean follow-up period was 3.80 ± 1.95 years.
During the index admission, 37% (n=62) underwent ERCP with ES.
Recurrent biliary pancreatitis (RBP) occurred in 35 patients (21%), 97% of whom had not undergone ES. Only one patient in the ES group was readmitted for a new episode of pancreatitis (p<0.001, OR 0.035; 95% CI 0.005–0.265). The mean time to recurrence was 2.67 ± 7.78 months. Kaplan-Meier survival analysis demonstrated a significantly lower cumulative incidence of RBP in the ES group (log-rank p<0.001).
Endoscopic sphincterotomy did not significantly reduce other biliary events, including choledocholithiasis, acute cholangitis, and acute cholecystitis (all p>0.05). There was no statistically significant difference in overall mortality between the two groups (p=0.585).

Conclusion

Our findings suggest that ERCP with ES may effectively reduce the recurrence of gallstone pancreatitis in elderly patients with high surgical-anesthetic risk due to comorbidities. Further studies are needed to refine the selection criteria for these patients.

References

1 - Hwang SS, Li BH, Haigh PI. Gallstone pancreatitis without cholecystectomy. JAMA Surg. 2013 Sep;148(9):867-72.
2 - McAlister, V., Davenport, E., & Renouf, E. (2007). Cholecystectomy deferral in patients with endoscopic sphincterotomy. Cochrane Database of Systematic Reviews.

Introduction

Chronic pancreatitis is a fibro-inflammatory syndrome of the pancreas with mixed etiology, multifactorial pathogenesis and persistent pathological response to parenchymal damage, characterized by chronic inflammation, endocrine dysregulation, malnutrition and malabsorption. These factors represent secondary causes of sarcopenia, a progressive and generalized skeletal muscle disease associated with an increased risk of adverse events including falls, fractures, physics disabilities and death.

Aims & Methods

This study aimed to evaluate the prevalence of sarcopenia in patients affected by chronic pancreatitis (eventually complicated by exocrine pancreatic insufficiency), to compare parameters of body composition, muscular strength and ultrasound muscle thickness between sarcopenic and non-sarcopenic patients, and to clarify the role of ultrasound in the diagnosis of sarcopenia compared to gold standard imaging (CT or MRI). 29 patients with diagnosis of chronic pancreatitis (according to the UEG criteria) were prospectively enrolled between February 2023 and September 2023. Data about anthropometric parameters, blood chemistry tests, fecal elastase, Body Indipendence Assessment (BIA), Hand Grip Strength and Sit To Stand test were collected. The presence of sarcopenia was assessed by CT or MRI at the third level lumbar vertebra, through the quantitative analysis of various muscles. Patients underwent muscle ultrasound to evaluate the echogenicity, thickness and length of different muscular fibers.

Results

The prevalence of radiologically defined sarcopenia was 34.5% (10/29). Among patients without exocrine pancreatic insufficiency, the prevalence of sarcopenia was 28.6%, resulting lower than the prevalence of sarcopenia among patients with exocrine pancreatic insufficiency treated with pancreatic enzyme replacement therapy (PERT) (37.5%) and without exocrine pancreatic insufficiency treated with PERT (40%). Evaluation of BMI did not show significant differences in the sarcopenic group compared to the non-sarcopenic group (21.5 vs 23.4 – p = 0.08). Sarcopenic patients showed significantly lower values of phase angle (4.85° vs 6.4°, p = 0.004), free fat mass (46.3 kg vs 56.6 kg, p = 0.02), body cell mass (22.9 kg vs 30.4 kg, p = 0.001), body cell mass index (7.8 vs 10.7, p = 0.004), total body water (32.2 L vs 41.4 L, p = 0.03) and a lower performance both in terms of strength at HGS (24.7 kg vs 38.4 kg, p = 0.003) and average power at STS test (33.3 W vs 102.2 W, p = 0.002). The rectus abdominis muscle and the left radial muscular compartment showed a statistically significant difference in terms of thickness between non-sarcopenic and sarcopenic patients (8.4 mm vs 6.9 mm - p = 0.003; 18.5 mm vs 15.7 mm - p = 0.004), with high accuracy in distinguishing the two groups (respectively AUC of 84% and 83%).

Conclusion

Sarcopenia is a highly prevalent comorbidity in patients suffering from chronic pancreatitis with or without exocrine pancreatic insufficiency, with an increasing prevalence of this condition along with the progression of the pancreatic disease. BMI does not represent a valid tool for assessing and monitoring the nutritional state. Muscle ultrasound has shown good diagnostic accuracy in diagnosis of sarcopenia compared with the radiological gold standard, when specific muscle groups are considered.