DIFFICULT CHOLECYSTECTOMY IN ACUTE BILIARY PANCREATITIS

Abstract. Introduction. The pathogenetic significance of cholelithiasis in acute pancreatitis has long been proven. Its pathogenesis has not been fully understood, and the mechanisms by which gallstones cause pancreatitis are currently debatable. Modern international approaches to cholecystectomy in patients with biliary pancreatitis are ambiguous in terms of the choice between index and interval cholecystectomy. Index cholecystectomy, which is performed in the early stages of acute pancreatitis, may be potentially more technically difficult than interval cholecystectomy, but with a combination of sufficient skills of the surgeon and modern equipment, it may be a feasible task with low risk for the patient. The aim. To assess the frequency and characteristics of difficult cholecystectomy in patients with acute biliary pancreatitis. Materials. This prospective study included 121 patients with acute biliary pancreatitis who underwent laparoscopic cholecystectomy as part of their surgical treatment. The difficulty of cholecystectomy was evaluated using the Vivek-Augustine scale (2014) and intraoperative criteria. Results. True intraoperative difficulties during cholecystectomy were observed in only 48 patients (39.7%). Analysis of the Vivek-Augustine scale in these patients showed a mean score of 24.08±12.09 (median 19.5; Q1 15.0; Q3 37.5; IQR 22.5). The surgical difficulties included initial port placement, difficult gallbladder traction, challenging dissection of Calot’s triangle, and difficult clipping of the cystic duct/artery. Significant intraoperative factors (p=0.001) included a thickened gallbladder wall, gallbladder empyema, gallbladder wall necrosis, edema of Calot’s triangle, unclear anatomy, ERCP within 24-48 hours, gallbladder perforation, cystic duct necrosis, a large stone in the gallbladder neck, significant bleeding, multiple stones in the cystic duct, and anatomical variations of the cystic duct/ artery. Conclusions. The frequency of difficult cholecystectomy in patients with acute biliary pancreatitis is highly overestimated. Intraoperative difficulties occur in 39.7 % of cases, and a potential difficult cholecystectomy should be considered when the Vivek-Augustine score is 15 or higher. In patients with acute biliary pancreatitis, intraoperative challenges during cholecystectomy can be effectively managed with sufficient surgical experience and high-quality equipment.