Review article

Surg Endosc (2003) 17: 1175–1180

DOI: 10.1007/s00464-002-9207-x

Springer-Verlag New York Inc. 2003

Acute biliary pancreatitis, endoscopy, and laparoscopy

F. Borie,1 A. Fingerhut,2 B. Millat1
1
Department of Visceral Surgery ÔAÕ, Hôpital Saint-Eloi, University Hospital Center Montpellier, Avenue Augustin Fliche 80,
F-34295 Montpellier Cedex 5, France
2
Department of Gastrointestinal Surgery, Centre Hospitalier Intercommunal Poissy, 10 rue du champ Gaillard, 78303 Poissy, France

Received: 16 September 2002/Accepted: 19 September 2002/Online publication: 14 March 2003

Abstract management of the more severe complications associ-

Current practices for diagnosis and treatment of com-
mon bile duct stones are not evidence-based. Acute
billary pancreatitis (ABP) is a specific situation in which
endoscopic procedures are either overused or misused.
Pancreatitis is a poor marker for choledocholithiasis.
Prognostic systems are accurate to discern those patients
with ABP who do not need aggressive procedures.
Patients with a benign ABP do not need an endoscopic
approach. Laparoscopic common bile duct exploration
is an underrated treatment for patients with choledo-
cholithiasis. Laparoscopic approach to infected necrotic
collections and pseudocysts warrant futher investiga-
tions.
Key words: Bilary pancreatitis — Endoscopic sphinc-
terotomy — Laparoscopic common bile duct explora-
tion — Pancreatic necrosis management
Acute biliary pancreatitis (ABP) occurs in 8–11% of
patients with biliary tract stones, with a reported at-
tending mortality ranging from 5% to 20% [5]. In sur-
gically fit patients, cholecystectomy is recommended to
prevent stone migration and recurrence. As laparoscopy
became the gold standard for cholecystectomy, modifi-
cations in the management of suspected or demon-
strated stones in the common bile duct (CBD) surfaced,
resulting in an increase in the number of preoperative
procedures, including endoscopic retrograde cholangi-
ography (ERC) and sphincterotomy (ES) to clear CBD
stones. Clearly, purported difficulty in the intraoperative
management of CBD stones has been at the root of this
policy. Controversial as well in the particular etiological
context of pancreatitis are the potential specific indica-
tions for ES. Minimal-access surgery to improve the
Correspondence to: B. Millat
ated with pancreatic and peripancreatic infected necrosis
is currently an area of clinical research. The aim of this
review is to evaluate, using the best available evidence,
whether the management of ABP should change in the
setting of modern laparoscopic biliary and pancreatic
surgery.
Pancreatitis and common bile duct stones
ABP is associated with the migration of CBD stones
through the papilla [2, 30]. A history of pancreatitis is
not in itself a significant indicator of the presence of
choledocholithiasis [27, 33, 55, 57, 58]. On the contrary,
a history of pancreatitis and rapid resolution of marked
hyperamylasemia might even help to identify those pa-
tients who are not likely to have choledocholithiasis [7,
16]. Several studies have indicated that the proportion of
patients found to harbor stones in the CBD declined
steadily following the onset of pancreatitis [4, 31, 66]. As
a consequence, if one accepts, for example, a 10% prior
probability (prevalence) of choledocholithiasis in the
general population, the probability that a patient will
have choledocholithiasis when increased amylasemia is
used as a predictive indicator would be only 14%,
whereas under the same conditions, this probability
would be 15% in case of acute cholecystitis [1]. Despite
this evidence, a population-based study has recently
shown that patients with ABP were more likely to have
preoperative investigations of the biliary tree, with
nearly one-third of patients scheduled for cholecystec-
tomy undergoing preoperative ERC, corresponding to a
proportion much higher than those with acute chole-
cystitis [8].
The reluctance of surgeons to perform intraopera-
tive cholangiograms (IOC) and, whenever indicated,
surgical exploration of the CBD is not in keeping with
the evidence. Savings in terms of both complications
and costs could be expected if preoperative ERC
performed for suspicion of choledocholithiasis was
1176
replaced by IOC [8, 13, 17]. Patients undergoing pre-
operative ERC for the management of gallstone pan-
creatitis are at increased risk for postprocedural
pancreatitis when compared with laparoscopic chole-
cystectomy with IOC [59]. When laparoscopic or open
cholecystectomy is performed for the management of
gallstone pancreatitis, IOC might be indicated regard-
less of the presumed risk of CBD stones. The risk of
biliary injury is increased in complex cases, including
biliary pancreatitis, operated on laparoscopically. IOC
has been shown to be associated with a reduction of this
risk [20, 21] and to shorten the delay for the diagnosis of
biliary injury [10, 73].
Assessment of severity of acute biliary pancreatitis
The clinical usefulness of an early objective assessment
of severity in acute pancreatitis became evident in 1974,
when Ranson et al. demonstrated that a scoring system,
based on age and 10 biological parameters reflecting
respiratory, renal, liver, and hematological disturbances
during the first 48 h of admission, was able to predict the
risk of death or major complications [53, 54]. Most
patients in the population studied by Ranson et al.,
however, had a history of alcohol abuse. A simplified
system (Imrie score) based on eight or nine factors was
validated later in patients, with cholelithiasis as the most
common etiologic association for acute pancreatitis [9,
29, 37, 48].
With both systems, the presence of three or more
signs was regarded as a marker of severity. However,
due to the advanced age of patients with gallstone
pancreatitis and to the early transient liver dysfunction
associated with biliary disease itself rather than with the
severity of pancreatitis, the Ranson score consistently
overestimates the severity of biliary pancreatitis.
Choosing specific biliary cutoff levels for some of the 11
criteria, a different scoring system was proposed to di-
minish this discrepancy [52]. In addition, shifting the
cutoff level from three to five criteria within the classic
Ranson score allowed the provision of a reliable dis-
crimination of severe biliary pancreatitis [40]. However,
the Ranson and Imrie multiple criteria systems are dis-
ease-specific and provide a ‘‘once only’’ estimate of se-
verity. Incomplete collection of data is common and
impairs accuracy. The Acute Physiology and Chronic
Health Enquiry (APACHE II) score can be calculated
immediately after admission and allows the monitoring
of patients with acute illness. The APACHE II score was
found to be at least as accurate as the Ranson and Imrie
scores [35], but it obviously did not fulfill the clinical
requirements of simplification for an early test of se-
verity in acute pancreatitis. Biologic assays such as a
plasma C-reactive protein (CRP) value > 210 mg/L [51,
72] or urinary trypsinogen activation peptide (TAP)
value > 35 nmol/L [46] 24–48 h after admission can
provide an accurate prediction of the severity of acute
pancreatitis and might be easier to adopt into routine
clinical practice than multiple-factor scoring systems.
Whatever the system used (Ranson, Imrie,
APACHE II, CRP, TAP) for the prediction of severity,
clinicians must be aware of their low positive predictive
value, which ranges from 0.30 to 0.44 [35, 46]. On the
other hand, the negative predictive values range from
0.85 to 0.96, with the higher negative predictive values
being reached by the Ranson or Imrie scores. The clin-
ical significance of these results is that prognostic pa-
rameters or scoring systems are more accurately used to
discern those patients who do not need aggressive pro-
cedures or treatment, rather than to predict those with a
potential complicated course.
Timing of surgery in acute biliary pancreatitis
The timing of biliary surgery depends on the severity of
pancreatitis. As early as 1981, Stone et al. compared
early and delayed biliary surgery in ABP in the first
randomized trial on the topic [66]. Unfortunately, in this
trial, the severity of pancreatitis was not assessed ob-
jectively, and the routine surgical treatment proposed
included a transduodenal sphincteroplasty, which was
highly questionable. For both of these reasons, the
conclusions of this trial cannot be considered to be
contributive. The best available evidence for the optimal
timing of biliary surgery in gallstone pancreatitis still
stems from the second randomized study published in
1988 [32], performed in traditional open biliary surgery:
A delay of at ‡3 days was strongly recommended to
allow the symptoms of the acute bout of severe pan-
creatitis to subside. The operation could be performed
earlier in benign cases and before hospital discharge in
the more severe cases.
Were there any reasons to question these evidence-
based recommendations because of the advent of lapa-
roscopic biliary surgery? In truth, no, but the conclusions
of different series of laparoscopic cholecystectomy
(LC) in ABP [62, 68, 70, 71] were that early operation
and Ranson’s score above three criteria were associated
with more technical difficulties and more conversions
to open surgery. The Consensus Panel of the SSAT,
AGE, and ASGE [63] agreed that LC was the procedure
of choice for removal of the gallbladder in patients
with biliary pancreatitis. They recommended IOC or
intraoperative ultrasound to ascertain the presence of
choledocholithiasis. If CBD stones are found at the
time of surgery, the options included transcystic lapa-
roscopic removal, laparoscopic choledochotomy, endo-
scopic antegrade sphincterotomy, conversion to an open
CBD exploration, or planned postoperative ERCP and
ES [63].
When is endoscopic sphincterotomy indicated in acute
biliary pancreatitis?
Mild acute pancreatitis
The role of urgent ERC is still controversial in ABP.
This controversy might well stem from a misunder-
standing of the pathophysiology of the disease, as well
as the reluctance of surgeons to perform the diagnosis

and treatment of CBD stones laparoscopically, leading
to an increasing frequency of preoperative ERC, just
because LC was planned. As previously stated, ABP
alone is a poor marker for the presence of choledocho-
lithiasis. Evidence from two randomized controlled tri-
als [19, 45] has shown that urgent ERC/ES does not
influence the local and general complication rates in
benign ABP.
Severe acute pancreatitis and cholangitis
While pancreatitis is a complication of small migrating
stones, cholangitis is a complication of large stones that
remain in the CBD. The incidence of acute cholangitis in
patients with biliary pancreatitis is 15% [44]. Evidence
from three randomized control trials [19, 22, 45] indi-
cates that combined pancreatitis and cholangitis may be
a factor of severity. In one of these trials [22], however,
all patients with cholangitis at admission had ES and
were not included in the randomization. Emergency
ERC (but not necessarily with ES) was associated with a
decreased general complication rate in one of three trials
[45], whereas in the two others [19, 22], the complication
rates were not different when cholangitis was excluded.
Moreover, one large retrospective series [36] and one
randomized study [34] have clearly shown that urgent
ES to drain the infected bile is beneficial in severe cho-
langitis.
In the absence of biliary sepsis or obstruction, there
are few but conflicting data pertaining to the need and
timing for ERC with or without ES in severe ABP [63].
There are no data to support the use of ES if, at the time
of ERCP done for suspected biliary pancreatic, no stone
is found.
Laparoscopic treatment of common bile duct stones
There has been a tremendous increase in the frequency
of ES for the treatment of CBDS in association with
laparoscopic cholecystectomy [8], but this attitude is not
evidence-based. Strikingly — and paradoxically — solid
scientific evidence has demonstrated that preoperative
ERC-ES followed by LC for a patient scheduled to
undergo LC, the most commonly advocated strategy in
a patient with suspicion of CBD stones, is also the least
efficient.
Once the stones are detected during LC, the extrac-
tion of CBD stones came as a logical extension of the
laparoscopic procedure. Laparoscopic exploration of
the CBD can be performed either through the cystic
duct or through laparoscopic choledochotomy. A criti-
cal evaluation of the retrospective and prospective series
on laparoscopic CBD exploration published since 1989
shows that both procedures are feasible and safe [38].
There is no justification for comparisons between the
two techniques, however, because of their obviously
different indications.
Preoperative ERC-ES was compared to postopera-
tive ERC-ES in a consecutive series of patients with mild
to moderate gallstone pancreatitis without cholangitis or
1177
necrotizing pancreatitis [13]. CBD stones were found in
12 of 30 patients (40%) randomized to routine preop-
erative ERC. Stone retrieval was successful in 11 of the
12 ES. Eight of 28 patients (28.5%) randomized to LC
without preoperative ERC had CBD stones, and seven
of them underwent postoperative therapeutic ERC with
ES. One patient had a choledochoduodenal fistula,
prompting conversion to open surgery. Mean hospital
stay was significantly longer and mean total cost was
significantly higher in the preoperative ERC as com-
pared with the postoperative ERC group (11.7 vs 9 days
and 9426 vs 7798, respectivey). A decision analysis as-
sessing different approaches for the use of ERC in pa-
tients undergoing LC [17] concluded that postoperative
ERC was associated with minimal costs and morbidity,
but laparoscopic CBD exploration was not considered
in the study design.
Because laparoscopic CBD exploration is considered
to be technically difficult and demanding, requiring ad-
vanced laparoscopic skills as well as expensive endo-
scopic and radiological equipment, ES has been
proposed as an alternative to the surgical management
of choledocholithiasis. None of the controlled studies
performed in open surgery has shown that ES, per-
formed either prior to surgery [43, 64, 65, 67] or in pa-
tients with gallbladder in situ [26, 69] was superior to the
single-step surgical management of gallbladder and
CBD stones. The conclusions reached by these rand-
omized trials were not extrapolated to laparoscopic
biliary surgery. Two additional randomized trials have
compared ES before [15, 18] and after [56] LC vs the
single-stage laparoscopic management in patients with
CBD stones. The European Association for Endoscopic
Surgery (EAES) multicenter randomized trial [15, 18]
compared endoscopic stone extraction followed by LC
(group A) vs LC with CBD exploration (group B). The
success rates for ERC and ES were 95.4% and 85%,
respectively, in group A. The total number of endo-
scopic procedures performed to achieve complete CBD
clearance was not reported. The success rate of IOC was
99.4% in group B, and laparoscopic CBD stone ex-
traction was successful in 82% of cases. Nineteen pa-
tients were converted to open surgery for ductal stone
clearance, and five patients underwent successful post-
operative ES. There were no significant differences be-
tween the two groups regarding the minor and major
postoperative complication rates. Patients with single-
stage surgical treatment were in hospital 3 days less than
patients with the two-stage management (p < 0.05).
In the second randomized trial [56], postoperative
ERC-ES was compared to laparoscopic exploration of
the CBD when ductal stones were demonstrated by
laparoscopic IOC. Thirty of the 40 patients (75%)
randomized to laparoscopic CBD exploration had their
ducts cleared at the time of surgery; nine patients re-
quired postoperative ERC-ES, and one was converted
to open surgery. Forty-six endoscopic procedures were
performed to achieve complete clearance of the CBD in
37 of 40 patients (93%) randomized to postoperative
ERC-ES. Two patients had a biliary stent after a failed
second ES; the last patient had choledocholithiasis left
in situ. Hospital stay, including all readmissions, was
1178
shorter (p < 0.001) after laparoscopic CBD exploration
(median, 1 day; range, 1–26) than after postoperative
ERC-ES (median, 3.5 days, range, 1–11).
ES, as an additional procedure to surgery, does not
improve the clinical results in patients fit for primary
single-stage surgical treatment, whether performed
laparoscopically or not. The notorious insufficiencies of
preoperative indicators for CBD stones should lead to
a requiem for preoperative invasive diagnostic proce-
dures. When IOC demonstrates CBD stones, appro-
priate treatment must be decided according to available
equipment and skills. In case of potential difficulties as
regards postoperative ERC-ES, a failed laparoscopic
CBD exploration will lead to open surgery. The
available data [13, 56] do not allow formal conclusions
regarding the alternative between advanced laparo-
scopic biliary explorations and postoperative ES. The
potential risk of reoperation in case of failed post-
operative ES might be more theoretical than practical
[13].
Laparoscopic management of pancreatic necrosis
Laparoscopic approach to infected necrotic collections
Symptomatic necrotic collections are amenable to
laparoscopic treatment, occasionally in addition to, or
in conjunction with, endoscopic and/or percutaneous
procedures. These include laparoscopic necrosectomy
and/or intracavitary debridement of peripancreatic
necrosis, laparoscopic-assisted percutaneous drainage,
sinus-tract endoscopy following percutaneous necro-
sectomy, and retroperitoneal endoscopic management
of peripancreatic necrosis. Anecdotal reports with small
numbers of patients or short series [3, 11, 23, 28] have
shown that the laparoscopic approach is feasible, but
the results do not differ significantly from those for the
standard open necrosectomy-lavage. Drainage proce-
dures, whatever their route (percutaneous, traditional,
or laparoscopic), seem to work better for infected col-
lections than for infected necrosis [39], although for the
latter, repeated and proper choice of caliber of drains
should also allow adequate drainage [6, 24, 41, 74].
Recently, video-assisted retroperitoneal drainage and
intracavitary transluminal debridement of peripancre-
atic necrosis have completed the therapeutic armamen-
tarium [3, 12, 23, 50]. The advantages of not opening the
abdominal cavity for these necessary, effective, but
otherwise devastating surgical procedures warrant fur-
ther investigation.
Laparoscopic management of pancreatic pseudocysts
Laparoscopic pancreatic cystogastrostomy [14] or
cystojejunostomy [25] are alternatives to the nonsurgical
techniques for organized necrotic collections [47, 49].
Laparoscopic drainage is becoming more popular be-
cause it allows for definitive drainage with faster patient
recovery [60]. For cystogastrostomy, the working area
can be through traditionally placed transabdominal
trocars [61] or through transgastric balloon trocars,
which are less invasive on the anterior gastric wall [42].
The results of these techniques, however, are presently
too scanty to draw any conclusions about their effec-
tiveness.
Conclusions
Antecedent pancreatitis is a poor indicator of CBD
stones. IOC is indicated during LC regardless of the risk
of CBD stones. The Ranson score overestimates the
severity of ABP. Other prognostic scores can discrimi-
nate patients with nonsevere ABP, and their negative
predictive value should help to avoid unnecessary di-
agnostic procedures and treatment in most cases. Cor-
rect timing of open or laparoscopic biliary surgery
depends on the severity of acute pancreatitis ES is not
indicated in mild ABP. ES is indicated in severe cho-
langitis associated with severe ABP. Surgical CBD ex-
ploration, open or laparoscopic, is more efficient than
ERC-ES. Performing ERC-ES after LC in patients with
stones demonstrated on IOC rather than before LC
minimizes costs and morbidity. The laparoscopic ap-
proach for necrotic collections is not a standard of care,
but it warrants further investigation. Laparoscopic
treatment of pancreatic cysts is feasible, but its clinical
effectiveness remains to be shown.
References
1. Abboud PAC, Malet PF, Berlin JA, Staroscik R, Cabana MD,
Clarke JR, Shea JA, Schwartz JS, Williams SV (1996) Predictors
of common bile duct stones prior to cholecystectomy: a meta-
analysis. Gastrointest Endosc 44: 450–459
2. Acosta JM, Ledesma CL (1974) Gallstone migration as a cause of
acute pancreatitis. N Engl J Med 290: 484–487
3. Alverdy J, Vargish T, Desai T, Frawley B, Rosen B (2000)
Laparoscopic intracavitary débridment of peripancreatic necrosis:
preliminary report and description of the technique. Surgery 127:
112–114
4. Armstrong CP, Taylor TV, Jeacock J, Lucas S (1985) The biliary
tract in patients with acute gallstone pancreatitis. Br J Surg 72:
551–555
5. Banerjee AK, Kaul A, Bache F, Parberry AC, Doran J, Nochllson
ML (1995) An audit of fatal acute pancreatitis. Postgrad Med J
71: 472–475
6. Baril NB, Ralls PW, Wren SM, Selby RR, Radin R, Parekh D,
Jabbour N, Stain SC (2000) Does an infected peripancreatic
fluid collection or abscess mandate operation? Ann Surg 231: 361–
367
7. Barkun AN, Barkun JS, Fried GM, Ghitulescu G, Steinmetz O,
Pham C, Meakins JL, Goresky CA (1994) Useful predictors of
bile duct stones in patients undergoing laparoscopic cholecystec-
tomy. Ann Surg 220: 32–39
8. Barwood NT, Valinsky LJ, Hobbs MST, Fletcher DR, Knuiman
MW, Ridout SC (2002) Changing methods of imaging the com-
mon bile duct in the laparoscopic cholecystectomy era in Western
Australia: implications for surgical practice. Ann Surg 235: 41–50
9. Blamey SL, Imrie CW, O’Neil J, Gilmour WH, Carter DC (1984)
Prognostic factors in acute pancreatitis. Gut 25: 1340–1346
10. Carroll BJ, Friedman RL, Liberman MA, Phillips EH (1996)
Routine cholangiography reduces sequelae of common bile duct
injuries. Surg Endosc 10: 1194–1197
11. Carter CR, McKay CJ, Imrie CW (2000) Percutaneous necro-
sectomy and sinus tract endoscopy in the management of in-
fected pancreatic necrosis: an initial experience. Ann Surg 232:
175–180

12. Castellanos G, Serrano A, Pinero A, Bru M, Parraga M, Marin P,
Parrilla P (2001) Retroperitoneoscopy in the management of
drained infected pancreatic necrosis. Gastrointest Endosc 53: 514–
515
13. Chang L, Lo S, Stabile BE, Lewis RJ, Toosie K, de Virgilio C
(2000) Preoperative versus postoperative endoscopic retrograde
cholangiopancreatography in mild to moderate gallstone pancre-
atitis: a prospective randomized trial. Ann Surg 231: 82–87
14. Chowbey PK, Soni V, Sharma A, Khuller R, Baijal M, Vashistha
A (2001) Laparoscopic intragastric stapled cystogastrostomy for
pancreatic pseudocyst. J Laparoendosc Adv Surg Tech 11: 201–
205
15. Cuschieri A, Lezoche E, Morino M, Croce E, Lacy A, Toouli J,
Faggioni A, Ribeiro VM, Jakimowicz JJ, Visa J, et al. (1999)
E.A.E.S multicenter prospective randomized trial comparing two-
stage vs single-stage management of patients with gallstone dis-
ease and ductal calculi. Surg Endosc 13: 952–957
16. Dougherty SH, Saltzstein EC, Peacock JB, Mercer LC, Cano P
(1988) Rapid resolution of high level hyperamylasemia as a guide
to clinical diagnosis and timing of surgical treatment in patients
with gallstones. Surg Gynecol Obstet 166: 491–496
17. Erickson RA, Carlson B (1995) The role of endoscopic retrograde
cholangiopancreatography in patients with laparoscopic chole-
cystectomies. Gastroenterology 109: 252–263
18. Cuschieri A, Croce E, Faggioni A, Jakimowicz JJ, Lacy A,
Lezoche E, Morino M, Ribeiro VM, Toouli J, Visa J (et al. 1996)
EAES ductal stone study: preliminary findings of multicenter
prospective randomized trial comparing two-stage vs single-stage
management. Surg Endosc European Association of Endoscopic
Surgeons (EAES) Ductal Stone Cooperative Group 10: 1130–
1135
19. Fan ST, Lai ECS, Mok FPT, Lo CML, Zheng SS, Wong J (1993)
Early treatment of acute biliary pancreatitis by endoscopic pap-
illotomy. N Engl J Med 328: 228–232
20. Fletcher DR, Hobbs MS, Tan P, Valinsky LJ, Hockey RL, Pikora
TJ, Knuiman MW, Sheiner HJ, Edis A (1999) Complications of
cholecystectomy: risks of the laparoscopic approach and protec-
tive effects of operative cholangiography: a population-based
study. Ann Surg 229: 449–457
21. Flum DR, Koepsell T, Heagerty P, Sinanan M, Dellinger P (2001)
Common bile duct injury during laparoscopic cholecystectomy
and the use of intraoperative cholangioqraphy: adverse outcome
or preventable error? Arch Surg 136: 1287–1292
22. Fölsch UR, Nitsche R, Lüdtke R, Hilgers RA, Creutzfeld W
(1997) Early ERCP and papillotomy compared with conservative
treatment for acute biliary pancreatitis. N Engl J Med 336: 237–
242
23. Gambiez LP, Denimal FA, Porte HL, Saudemont A, Chambon
JPM, Quandalle PA (1998) Retroperitoneal approach and endo-
scopic management of peripancreatic necrosis collections. Arch
Surg 133: 66–72
24. Gouzi JL, Bloom E, Julio C, Labbe F, Sans N, el Rassi Z, Carrere
N, Pradere B (1999) Percutaneous drainage of infected pancreatic
necrosis: an alternative to surgery. Chirurgie 124: 31–37
25. Hagopian EJ, Teixeira JA, Smith M, Steichen FM (2000) Pan-
creatic pseudocyst treated by laparoscopic Roux-en-Y cystojeju-
nostomy: report of a case and review of the literature. Surg
Endosc 14: 967
26. Hammarström LE, Holmin T, Stridbeck H, Ihse I (1995) Long-
term follow-up of a prospective randomized study of endoscopic
versus surgical treatment of bile duct calculi in patients with
gallbladder in situ. Br J Surg 82: 1516–1521
27. Hauer-Jensen M, Karesen R, Nygaard K, Solheim K, Amlie E,
Havig ø, Viddal KO (1985) Predictive ability of choledocholithi-
asis indicators: a prospective evaluation. Ann Surg 202: 64–68
28. Horvath KD, Kao LS, Wherry KL, Pellegrini CA, Sinaman MN
(2001) A technique for laparoscopic-assisted percutaneous drain-
age of infected pancreatic necrosis and pancreatic abscess. Surg
Endosc 15: 1221–1225
29. Imrie CW, Benjamin IS, Ferguson DC, Mackay AJ, Mackensie I,
O’Neill J, Blumgart LH (1978) A single centre double-blind trial
of Trasylol therapy in primary acute pancreatitis. Br J Surg 65:
337–341
30. Kelly TR (1976) Gallstone pancreatitis: pathophysiology. Surgery
80: 488–492
1179
31. Kelly TR, Swaney PE (1982) Gallstone pancreatitis: the second
time around. Surgery 92: 571–575
32. Kelly TR, Wagner DS (1988) Gallstone pancreatitis: a prospective
randomized trial of the timing of surgery. Surgery 104: 600–605
33. Koo KP, Traverso W (1996) Do preoperative indicators predict
the presence of common bile duct stones during laparoscopic
cholecystectomy? Am J Surg 171: 495–499
34. Lai ECS, Mok FPT, Tan ESY, Lo CM, Fan ST, You KT (1992)
Endoscopic biliary drainage for severe acute cholangitis. N Engl J
Med 326: 1582–1586
35. Larvin M, McMahon MJ (1989) APACHE II score for assessment
and monitoring of acute pancreatitis. Lancet 2: 201–204
36. Leese T, Neoptolemos JP, Baker AR, Carr-Locke DL (1986)
Management of acute cholangitis and the impact of endoscopic
sphincterotomy. Br J Surg 73: 988–992
37. Leese T, Shaw D (1988) Comparison of three Glasgow multifactor
prognostic scoring systems in acute pancreatitis. Br J Surg 75:
460–462
38. Memon MA, Hassaballa H, Memon MI (2000) Laparoscopic
common bile duct exploration: the past, the present, and the fu-
ture. Am J Surg 179: 309–315
39. Millat B, Borie F, Guillon F (2001) Surgical treatment of sterile
and infected pancreatic and peri-pancreatic necrosis. Gastroen-
terol Clin Biol 25: 1S112–1S118
40. Millat B, Fingerhut A, Gayral F, Zazzo JF, Brivet F (1992) Pre-
dictability of clinicobiochemical scoring systems for early identi-
fication of severe gallstone-associated pancreatitis. Am J Surg 164:
32–38
41. Mithöfer K, Mueller PR, Warshaw AL (1997) Interventional and
surgical treatment of pancreatic abscess. World J Surg 21: 162–168
42. Mori T, Abe N, Sugiyama M, Atomi Y, Way LW (2000) Lapa-
roscopic pancreatic cystogastrostomy. J Hepatobil Pancreat Surg
7: 28–34
43. Neoptolemos JP, Carr-Locke DL, Fossard DP (1987) Prospective
randomised study of preoperative endoscopic Sphincterotomy
versus surgery alone for common bile duct stones. Br Med J 294:
470–474
44. Neoptolemos JP, Carr-Locke DL, Leese T, James D (1987) Acute
cholangitis in association with acute pancreatitis: incidence, clin-
ical features and outcome in relation to ERCP and endoscopic
sphincterotomy. Br J Surg 74: 1103–1106
45. Neoptolemos JP, Carr-Locke DL, London NJ, Bailey IA, James
D, Fossard DP (1988) Controlled trial of urgent endoscopic ret-
rograde cholangiopancreatography and endoscopic sphincteroto-
my versus conservative treatment for acute pancreatitis due to
gallstones. Lancet 2: 979–983
46. Neoptolemos JP, Kemppainen EA, Mayer JM, Fitzpatrick JM,
Raraty MG, Slavin J, Beger HG, Hietaranta AJ, Puolakkainen
PA (2000) Early prediction of severity in acute pancreatitis by
urinary trypsinogen activation peptide: a multicentre study. Lan-
cet 355: 1955–1960
47. Oria A, Ocampo C, Zandalazini H, Chiapetta L, Moran C (2000)
Internal drainage of giant acute pseudocysts: the role of video-
assisted pancreatic necrosectomy. Arch Surg 135: 136–140
48. Osborne DH, Imrie CW, Carter DC (1981) Biliary surgery in the
same admission for gallstone associated acute pancreatitis. Br J
Surg 68: 758–761
49. Park A, Schwartz R, Tandan V, Anvari M (1999) Laparoscopic
pancreatic surgery. Am J Surg 177: 158–163
50. Prinz RA, Olen R (1991) Endoscopic evaluation of infected pan-
creatic necrosis. Surg Laparosc Endosc 1: 195–197
51. Puolakkainen P, Valtonen , Paanaven A, Schröder TC (1987) C-
reactive protein (CRP) and serum phospholipase A2 in the as-
sessment of the severity of acute pancreatitis. Gut 18: 764–771
52. Ranson JHC (1979) The timing of biliary surgery in acute pan-
creatitis. Ann Surg 189: 654–663
53. Ranson JHC, Rifkind KM, Roses DF, Fink SD, Eng K, Spencer
RC (1974) Prognostic signs and the role of operative management
in acute pancreatitis. Surg Gynecol Obstet 139: 68–81
54. Ranson JHC, Rifkind KM, Turner JW (1976) Prognostic signs
and nonoperative peritoneal lavage in acute pancreatitis. Surg
Gynecol Obstet 143: 209–219
55. Reiss R, Deutsch AA, Nudelman I, Kott I (1984) Statistical value
of various clinical parameters in predicting the presence of chol-
edochal stones. Surg Gynecol Obstet 159: 273–276
1180
56. Rhodes M, Sussman L, Cohen L, Lewis MP (1998) Randomized
trial of laparoscopic extraction of common bile duct versus
postoperative endoscopic retrograde cholangiography for com-
mon bile duct stones. Lancet 351: 159–162
57. Robertson GSM, Jagger C, Johnson PRV, Rathbone BJ, Wicks
ACB, Lloyd DM, Veitch PS (1996) Selection criteria for preop-
erative endoscopic retrograde cholangiopancreatography in the
laparoscopic era. Arch Surg 131: 89–94
58. Saltzstein EC, Peacock JB, Thomas MD (1982) Preoperative bi-
lirubin, alkaline phosphatase and amylase levels as predictors of
common duct stones. Surg Gynecol Obstet 154: 381–384
59. Sees DW, Martin R (1997) Comparison of preoperative endo-
scopic retrograde cholangiopancreatography and laparoscopic
cholecystectomy with operative management of gallstone pan-
creatitis. Am J Surg 174: 719–722
60. Siperstein A (2001) Laparoscopic approach to pancreatic pseu-
docysts. Semin Laparosc Surg F 8: 218–222
61. Smadja C, Badawy A, Vons C, Giraud V, Franco D (1999)
Laparoscopic cystogastrostomy for pancreatic pseudocyst is safe
and effective. J Laparoendosc Adv Surg Tech 9: 401–403
62. Soper NJ, Brunt LM, Callery MP, Edmundowicz SA, Aliperti G
(1994) Role of laparoscopic cholecystectomy in the management
of acute gallstone pancreatitis. Am J Surg 167: 42–51
63. SSAT, AGE, ASGE, Consensus Panel (2001) Management of the
biliary tract in acute necrotizing pancreatitis. J Gastrointest Surg
5: 221–222
64. Stain SC, Chohen H, Tsuishoyasha M, Donovan AJ (1991)
Choledocolithiasis endoscopic sphincterotomy or common bile
duct exploration. Ann Surg 213: 627–634
65. Stiegman GV, Goff JS, Mansour A, Pearlman N, Reveille RM,
Norton L (1992) Precholecystectomy endoscopic cholangiography
and stone removal is not superior to cholecystectomy, cholangi-
ography and common duct exploration. Am J Surg 163: 227–230
66. Stone HH, Fabian TC, Dunlop WE (1981) Gallstone pancreatitis:
Biliary tract pathology in relation to time of operation. Ann Surg
194: 305–312
67. Suc B, Escat J, Cherqui D, Fourtanier G, Hay JM, Fingerhut A,
Millat B (1998) Surgery vs endoscopy as primary treatment in
symptomatic patients with suspected common bile duct stones:
a multicenter prospective randomized trial. Arch Surg 133: 702–
708
68. Tang E, Stain SC, Tang G, Froes E, Berne TV (1995) Timing of
laparoscopic surgery in gallstone pancreatitis. Arch Surg 130:
496–500
69. Targarona EM, Ayuso RMP, Bordas JM, Ros E, Pros I, Martinez
J, Teres J, Trias M (1996) Randomised trial of endoscopic
sphincterotomy with gallbladder left in situ versus open surgery
for common bile duct calculi in high-risk patients. Lancet 347:
926–929
70. Tate JJT, Lau WY, Li AKC (1994) Laparoscopic cholecystectomy
for biliary pancreatitis. Br J Surg 81: 720–722
71. Uhl W, Muller CA, Krahenbuhl L, Schmid SW, Scholzel S,
Buchler MW (1999) Acute gallstone pancreatitis: timing of lapa-
roscopic cholecystectomy in mild and severe disease. Surg Endosc
13: 1070–1076
72. Wilson C, Heads A, Shenkin A, Imrie CW (1989) C-reactive
protein, antiproteases and complement factors as objective
markers of severity in acute pancreatitis. Br J Surg 76: 177–181
73. Woods MS, Traverso LW, Kozarek RA, Donohue JH, Fletcher
DR, Hunter JG, Oddsdottir M, Rossi RL, Tsao J, Windsor J
(1995) Biliary tract complications of laparoscopic cholecystectomy
are detected more frequently with routine intraoperative cho-
langiography. Surg Endosc 10: 1076–1080
74. Zins M, Delattre JF, Lenoir S, Strauss C, Gayet B, Palau R (2001)
Treatment of sterile and infected necrosis: the role of interven-
tional radiology. Gastroenterol Clin Biol 25: 1S119–1S121