Cholecystectomy Optimally Performed Within 8 Weeks for Necrotizing Biliary Pancreatitis
Bret T. Petersen, MD, MASGE, reviewing Hallensleben ND, et al. Gut 2021 Jul 16.
Cholecystectomy before hospital dismissal is advised for most cases of acute biliary pancreatitis (ABP). Surgery is often delayed in the setting of pancreatic necrosis to ensure stabilization of associated fluid collections and absence of potentially complicating inflammation. The optimal interval for safe and effective cholecystectomy in this group of patients is not well-defined.
The Dutch Pancreatitis Study Group undertook this post hoc analysis of their multicenter prospective cohort of patients with ABP to identify (1) the interval to surgery with the lowest risks for both surgical complications and recurrent biliary events and (2) the benefit of clinically indicated endoscopic sphincterotomy during the preoperative interval.
All 248 patients from 27 centers had ABP with a CT severity score of >3 and were dismissed from the hospital with intact gallbladders. Overall, 191 patients (77%) subsequently underwent cholecystectomy, most within 46 to 222 days (median, 103 days). One-quarter of these patients underwent an open cholecystectomy. Recurrent pancreatitis prior to cholecystectomy occurred in 9% of patients, whereas overall biliary events occurred in 27% of all patients, and 35% of those going on to cholecystectomy. The risk of recurrent ABP was lower in the first 8 weeks following dismissal (risk ratio [RR], 0.14; P=.02), and overall biliary events were significantly lower within 10 weeks of dismissal than thereafter (RR, 0.49; P=.02). Endoscopic biliary sphincterotomy failed to reduce the rate of recurrent ABP or overall biliary events (odds ratio, 1.40; 95% confidence interval, 0.74-2.83). Four patients (2%) developed infected necrosis following cholecystectomy, all of whom had persistent fluid collections less than 2 weeks before surgery. Overall surgical complication rates did not decline over time.
COMMENTThe authors conclude “the optimal timing of cholecystectomy after necrotizing biliary pancreatitis, in the absence of peripancreatic collections, is within 8 weeks after discharge.” Preoperative imaging is advisable, and immature or persistently large collections of fluid certainly warrant further deferral of surgery and reimaging every 2 to 4 weeks, with or without drainage or directed therapy, based on their size, location, and clinical effects. The lack of benefit from endoscopic sphincterotomy during the preoperative interval in this study differs from the modest benefit noted in several other studies. That potential benefit should be weighed against the risk of ERCP-induced contamination of persistent fluid collections.
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)
Hallensleben ND, Timmerhuis HC, Hollemans RA, et al. for the Dutch Pancreatitis Study Group. Optimal timing of cholecystectomy after necrotising biliary pancreatitis. Gut 2021 Jul 16. (Epub ahead of print) (http://dx.doi.org/10.1136/gutjnl-2021-324239)
