Surgery for gallstone pancreatitis.

Operative intervention during an attack of biliary pancreatitis is an effective way to treat the associated biliary tract disease and prevent the development of future attacks. Laparoscopic cholecystectomy has now emerged as the procedure of choice to treat cholelithiasis, but the treatment of associated choledocholithiasis is not yet defined. There are currently two possible approaches to these patients: First, early endoscopic retrograde cholangiopancreatography (ERCP) to determine if stones are present within the bile duct and, if so, early endoscopic sphincterotomy. If this approach is followed, then laparoscopic cholecystectomy should be performed as soon as the acute symptoms have subsided. On the other hand, if ERCP is not performed early and there are no obvious signs of biliary obstruction, laparoscopic cholecystectomy should probably be performed just before the patient is discharged. By waiting 5 to 6 days after the onset of the attack, the chances of finding associated choledocholithiasis are minimized. At the time of laparoscopic cholecystectomy, a cholangiogram must be obtained. If choledocholithiasis is found, the common bile duct may be explored via laparoscopic techniques, the operation may be converted to an open procedure, or the patient may be scheduled for endoscopic sphincterotomy for the next day.