Don't delay cholecystectomy in biliary pancreatitis.
Current guidelines suggest that it may be acceptable to discharge the patient after resolution of the pancreatitis and then wait 2-4 weeks to perform the operation (Gut 2005;54:1-9; Gastroenterology 2007;132:2019-21). But in a retrospective study, Dr.Ito of Harvard Medical School, Boston, and her colleagues found that delays in cholecystectomy were associated with a high incidence of gallstone-related events, a longer overall length of stay, and worse postoperative outcomes.
Furthermore, performing endoscopic sphincterotomy does not eliminate the risk of recurrent pancreatitis or other gallstone-related events, Dr. Ito said.
The study included 281 patients with biliary pancreatitis; those with necrotizing pancreatitis were excluded. Of the study patients, 162 (group A) underwent cholecystectomy during their initial admission and the other 119 (group B) underwent cholecystectomy on a subsequent admission. The two groups were similar in terms of demographics, comorbidities, and the severity of their pancreatitis. However, a significantly larger proportion of the patients in group A were female (72% vs. 61%).
In group B, during the interval between discharge and cholecystectomy, 39 of the patients (33%) experienced a gallstone-related event. In addition, 16 of those,39 patients had recurrent pancreatitis. Overall, 50% of the patients experiencing recurrent pancreatitis did so within 4 weeks of their initial discharge.
Group A and group B differed significantly on total length of hospital stay: 5 days on average for group A and 7 days for group B (including both hospital admissions). Patients in group A also fared better than those in group B in terms of postoperative recurrence of biliary pancreatitis (3% vs. 10%) and reoperation (0% vs. 3%). There were no statistically significant differences between the groups in readmission after the operation or in perioperative morbidity, and no patients in either group died during the perioperative period.
Endoscopic sphincterotomies were performed in 42 (35%) of the group B patients during the initial hospital admission. The total proportion of gallstone-related events did not differ between the patients who underwent a sphincterotomy and those who did not.
A greater proportion of patients who underwent sphincterotomies experienced acute cholecystitis (12% vs. 1%), but 18% of patients who did not receive a sphincterotomy had recurrent pancreatitis, vs. 5% of those who did. These two differences were statistically significant.
During the question and answer period after the presentation, one physician asked whether there could have been selection bias in this retrospective study. He suggested that there may have been some unknown but systematic difference between the patients who received a cholecystectomy during their initial admission and those who waited. Dr. Ito acknowledged that she could not exclude this possibility.
Dr. Ito stated that she had no relevant financial relationships associated with her presentation.
BY ROBERT FINN San Francisco Bureau
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|Publication:||Internal Medicine News|
|Date:||May 1, 2008|
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