Cholecystectomy Before Dismissal Confirmed as Optimal in Large Population of Veterans With Biliary Pancreatitis
Bret T. Petersen, MD, FASGE, reviewing Kohli DR, et al. Clin Gastroenterol Hepatol 2020 Dec 8.
Multiple guidelines recommend performing cholecystectomy (CCy) before hospital dismissal for patients with mild gallstone pancreatitis that is not complicated by infection or necrosis. In this retrospective study, the authors sought to define the outcomes of deviation from this practice using a large Veteran’s Administration data repository.
Between January 1, 2009, and December 31, 2018, of 9426 patients with biliary pancreatitis, 2830 (30%) underwent “index” CCy before dismissal, 1830 (19.4%) underwent “interval” CCy at a median of 92 days following dismissal, and 4766 (50.32%) did not undergo CCy. In the no-CCy group, 283 (5.9%) patients underwent ERCP.
The primary outcome of readmission for gallstone pancreatitis occurred in 8.5% of the index CCy group, 7.8% of the interval CCy group, and 14.6% of the no-CCy group (P<.001). Compared to the index group, the adjusted odds ratio for readmission was significant only for the no-CCy group (1.80; 95% CI, 1.58-2.05; P<.001). Odds ratios for cholangitis were significantly increased for interval CCy, and odds ratios for jaundice were increased for both index CCy and no-CCy. Over time, the incidence of interval CCy decreased in favor of index CCy; however, the incidence of no-CCy did not change significantly. The no-CCy group had significantly more comorbidities and greater rates of death during the index hospitalization and the subsequent 5-year interval.
COMMENTThis study, from a large database incorporating both inpatient and outpatient experience, confirms previous studies that demonstrate reduced rates of recurrent biliary pancreatitis and associated comorbidities when cholecystectomy is performed before dismissal from the index episode. This approach has also been shown to be more cost-effective than planned or symptom-driven interval cholecystectomy. Prophylactic biliary sphincterotomy, often proposed for patients with significant surgical risk, has been shown to reduce the rate of recurrent pancreatitis by about half but is not a panacea for this patient group.
Note to readers: At the time we reviewed this paper, its publisher noted that it was not in final form and that subsequent changes might be made.
CITATION(S)
Kohli DR, Desai M, Kennedy KF, Parasa S, Sharma P. Cholecystectomy for biliary pancreatitis is often not performed during index hospitalization and is associated with worse outcomes. Clin Gastroenterol Hepatol 2020 Dec 8. (Epub ahead of print) (https://doi.org/10.1016/j.cgh.2020.12.002)
