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Timing of cholecystectomy after mild biliary pancreatitis


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Momento para realizar colecistectomia despues de un cuadro de pancreatitis biliar

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Timing of cholecystectomy after mild biliary pancreatitis

  1. 1. REVIEW Timing of Cholecystectomy After Mild Biliary Pancreatitis A Systematic ReviewMark C. van Baal, MD,∗ Marc G. Besselink, MD, PhD,† Olaf J. Bakker, MD,† Hjalmar C. van Santvoort, MD, PhD,† Alexander F Schaapherder, MD, PhD,‡ Vincent B. Nieuwenhuijs, MD, PhD,§ Hein G. Gooszen, MD, PhD,∗ . Bert van Ramshorst, MD, PhD,|| and Djamila Boerma, MD, PhD , for the Dutch Pancreatitis Study Group costs of acute pancreatitis currently exceed $2.2 billion.3 In 80%Objectives: To determine the risk of recurrent biliary events in the period after of patients the pancreatitis remains mild, however, 20% of patientsmild biliary pancreatitis but before interval cholecystectomy and to determine develop severe pancreatitis, which is associated with high morbiditythe safety of cholecystectomy during the index admission. and mortality.4Background: Although current guidelines recommend performing cholecys- It is generally accepted that patients with severe biliary pan-tectomy early after mild biliary pancreatitis, consensus on the definition of creatitis should undergo cholecystectomy when signs of inflam-early (ie, during index admission or within the first weeks after hospital dis- mation have resolved (ie, interval cholecystectomy).5 After mildcharge) is lacking. biliary pancreatitis current international guidelines advice “early”Methods: We performed a systematic search in PubMed, Embase, and cholecystectomy.6–8 The definition of “early”, however, varies greatlyCochrane for studies published from January 1992 to July 2010. Included between guidelines. The International Association of Pancreatologywere cohort studies of patients with mild biliary pancreatitis reporting on (IAP) recommends that all patients with gallstone pancreatitis shouldthe timing of cholecystectomy, number of readmissions for recurrent biliary undergo cholecystectomy as soon as the patient has recovered fromevents before cholecystectomy, operative complications (eg, bile duct injury, the attack,8 whereas the American Gastroenterological Association7bleeding), and mortality. Study quality and risks of bias were assessed. and the British Society of Gastroenterology6 recommend cholecys-Results: After screening 2413 studies, 8 cohort studies and 1 randomized tectomy within a 2- to 4-week interval after discharge. This lacktrial describing 998 patients were included. Cholecystectomy was performed of consensus is also reflected by several audits from the Unitedduring index admission in 483 patients (48%) without any reported readmis- Kingdom,9–11 Germany,12 Italy,13 and a large database study fromsions. Interval cholecystectomy was performed in 515 patients (52%) after 40 the United States.14 The differences between these guidelines aredays (median; interquartile range: 19–58 days). Before interval cholecystec- most likely caused by a lack of randomized controlled studies on thistomy, 95 patients (18%) were readmitted for recurrent biliary events (0% vs topic. The rationale of early cholecystectomy is to reduce the risk18%, P < 0.0001). These included recurrent biliary pancreatitis (n = 43, 8%), of recurrent biliary events (eg, recurrent biliary pancreatitis, acuteacute cholecystitis (n = 17), and biliary colics (n = 35). Patients who had an cholecystitis, symptomatic choledocholithiasis, biliary colics). Thisendoscopic retrograde cholangiopancreatography had fewer recurrent biliary may be essential, as a recurrent attack of biliary pancreatitis could beevents (10% vs 24%, P = 0.001), especially less recurrent biliary pancreatitis severe and thus life threatening.15(1% vs 9%). There were no differences in operative complications, conversion In the case of clinical equipoise, the situation where no clearrate (7%), and mortality (0%) between index and interval cholecystectomy. therapeutic recommendation can be made, many clinicians routinelyBecause baseline characteristics were only reported in 26% of patients, study perform interval cholecystectomy because this does not stress thepopulations could not be compared. usually already busy emergency theatre list, and for reimbursementConclusions: Interval cholecystectomy after mild biliary pancreatitis is asso- reasons.12 Therefore, it is essential to quantify the risks involved withciated with a high risk of readmission for recurrent biliary events, especially interval cholecystectomy as compared with cholecystectomy duringrecurrent biliary pancreatitis. Cholecystectomy during index admission for index admission (index cholecystectomy) and to grade the currentmild biliary pancreatitis appears safe, but selection bias could not be excluded. evidence on this topic.(Ann Surg 2012;255:860–866) We performed the first systematic review on timing of chole- cystectomy after mild biliary pancreatitis, and focused on (1) the riskT he incidence of acute biliary pancreatitis is increasing worldwide, possibly due to an increase in obesity with associated increasedrisk of gallstone disease.1,2 In the United States alone, the annual of recurrent biliary events in the period between discharge after mild biliary pancreatitis and interval cholecystectomy and (2) the safety of index versus interval cholecystectomy after mild biliary pancreatitis. METHODSFrom the ∗ Department of Operating Room/Evidence Based Surgery, Radboud University Nijmegen Medical Centre, Nijmegen; †Department of Surgery, Uni- Systematic Literature Search versity Medical Center, Utrecht; ‡Department of Surgery, Leiden University Medical Center, Leiden; §Department of Surgery, University Medical Center A systematic literature search was performed in the PubMed, Groningen, Groningen; and ||Department of Surgery, St Antonius Hospital, Embase, and Cochrane Library databases from January 1, 1992, to Nieuwegein, the Netherlands. July 31, 2010. We adhered to the 2009 PRISMA statement.16 TheDisclosure: The authors declare no conflicts of interest. search was limited to this episode, as before 1992 no universallyPresented at the Pancreas Club 2010 (May 1, 2010, New Orleans, Louisiana) and the European Pancreatic Club 2010 (June 17, 2010, Stockholm, Sweden). accepted terms were available for acute pancreatitis and its clinicalReprints: Marc G. H. Besselink, MD, PhD, Dutch Pancreatitis Study Group, course. In 1992, the Atlanta symposium provided clear definitions of Department of Surgery, University Medical Center Utrecht, HP G04.228, the disease and its complications.17 Although the Atlanta classifica- PO Box 85500, 3508 GA Utrecht, the Netherlands. E-mail: m.besselink@ tion is currently under revision, the definitions have been widely used C 2012 by Lippincott Williams & Wilkins in the literature since 1992.ISSN: 0003-4932/12/25505-0860 The MeSH headings “cholecystectomy” and “pancreatitis”DOI: 10.1097/SLA.0b013e3182507646 were used, and the search was restricted to English literature. From the860 | Annals of Surgery r Volume 255, Number 5, May 2012 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  2. 2. Annals of Surgery r Volume 255, Number 5, May 2012 Timing of Cholecystectomy After Mild Biliary Pancreatitisstudies identified, all titles and abstracts were screened to select those in the timing of cholecystectomy (ie, less sick patients undergoingreporting on the timing of cholecystectomy in patients with mild bil- index cholecystectomy more frequently). Finally, we assessed reasonsiary pancreatitis. Subsequently, full-text papers of the selected studies for delay of cholecystectomy.were independently screened by 2 authors (M.v.B. and M.B.) for el-igibility. When multiple articles were published by the same study Statistical Analysisgroup and no difference in study period was described, only the most All data were pooled. Total number of readmissions due to re-recent paper was selected for this systematic review. current biliary events was calculated, and every recurrent biliary event apart and compared between the patients with early cholecystectomyInclusion and Exclusion Criteria and interval cholecystectomy. Regarding the number of recurrent bil- Inclusion criteria were (1) cohort of patients undergoing chole- iary events before cholecystectomy, comparison was made by patientscystectomy after mild biliary pancreatitis (ie, either index or interval with or without ERCP before cholecystectomy. Baseline characteris-cholecystectomy); (2) information on the following essential out- tics were listed, and the number of complications occurred. Mortalitycomes: time between recovery from acute pancreatitis and cholecys- and conversion rates were calculated and compared between patientstectomy, number of recurrent biliary events prior to cholecystectomy, with early and interval cholecystectomy.complications during the cholecystectomy (eg, bile duct injury, bleed- Nonnormally distributed data were presented as median (in-ing), and mortality. terquartile range). Proportions were compared by the χ 2 test or the Exclusion criteria were (1) cohorts with fewer than 5 patients; Fisher exact test, as appropriate. All statistical analyses were per-(2) cohorts including severe pancreatitis without reporting the results formed using SPSS for Windows version 16.0.2 (SPSS, Chicago,for mild pancreatitis separately; (3) cohorts without reporting on IL). Two-sided P < 0.05 was considered statistically significant.essential outcomes; (4) cohorts in which patients underwent indexcholecystectomy during the initial attack of acute pancreatitis (ie, RESULTSbefore recovery); the rationale for this being that the IAP guidelineadvices cholecystectomy only after recovery of biliary pancreatitis.8 Included Studies All references of the included studies were screened for poten- The results of the literature search are depicted in Figure 1. Thetial relevant studies not identified by the initial literature search. The initial search yielded 2413 potentially relevant articles papers. Afterfinal decision on eligibility was reached by consensus between the 2 screening titles and abstracts for relevance, 38 remaining articles werescreening authors. further assessed for eligibility. Although all 38 articles reported on the timing of cholecystectomy in biliary pancreatitis, 29 were ex-Data Extraction cluded for the following reasons: cohort of patients not reporting on From the included studies, the following variables were ex- the incidence of recurrent biliary events before cholecystectomy (n =tracted (if available): definition of mild biliary pancreatitis, number 9),15,20–27 cohorts of patients with mixed severe and mild acute bil-of patients undergoing cholecystectomy after mild biliary pancre- iary pancreatitis and outcomes not reported separately (n = 6),11,28–32atitis, number of endoscopic retrograde cholangiopancreatography cohorts of patients without data on the period between index admis-(ERCP) and endoscopic sphincterotomy performed, time between sion and cholecystectomy (n = 5),10,33–36 cohorts where no sepa-first hospital admission and cholecystectomy, reasons for delay of rate results were described for patients with acute biliary pancreatitissurgery, number of re-admissions during time between first hospi- (n = 4),37–40 cohorts in which patients were operated during the initialtal admission and cholecystectomy, total number of recurrent biliary attack of pancreatitis (n = 3),41–43 cohorts with fewer than 5 patientsevents (ie, biliary pancreatitis, acute cholecystitis and biliary colics) per study group (n = 1),44 and cohorts without documentation ofrequiring readmission during time between first hospital admissionand cholecystectomy, conversion to open cholecystectomy, complica-tions, and mortality. If reported, follow-up and data of patients withrecurrent biliary pancreatitis after cholecystectomy were extracted.The authors of included studies were contacted if one of these vari-ables could not be extracted from the original article. We definedindex cholecystectomy as cholecystectomy during the initial hospi-tal admission for acute biliary pancreatitis. Interval cholecystectomywas defined as cholecystectomy during a new hospital admission forcholecystectomy, usually performed at least 1 week after discharge.Assessment of Study Quality We performed a quality assessment of the included studieswith 2 previously validated checklists that scored the methodologicalquality of nonrandomized studies.18,19 Downs and Black18 describeda checklist with 27 items (one point for each item), which can beused for quality assessment for both randomized and nonrandomizedstudies. The MINORS checklist, described by Slim et al, contains8 items for noncomparative studies and 12 items for comparativestudies (maximum of 2 points for each item).19 In both lists, a lowscore reflects a high risk of bias, whereas a high score reflects a lowrisk of bias. To facilitate comparison of both lists, each score wasconverted to a score on a 0 to 10 scale. Randomized controlled trialswere only assessed with the checklist of Downs and Black. No studieswere excluded on the basis of their score. Baseline characteristics were FIGURE 1. PRISMA flowchart systematic review of timing ofassessed to determine whether selection bias might have played a role cholecystectomy after mild biliary pancreatitis.C 2012 Lippincott Williams & Wilkins | 861 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  3. 3. van Baal et al Annals of Surgery r Volume 255, Number 5, May 2012essential outcomes (n = 1)45 . Finally, 9 studies were included in the curred in 14 (10%) of 136 patients, due to recurrent biliary pancreatitiscurrent systematic review.9,46–53 Six studies were retrospective cohort in 2 patients, acute cholecystitis in 5 patients, and biliary colics in 7studies,9,48–51,53 2 studies were prospective cohort studies,47,52 and 1 patients. Notably, of 197 patients without previous ERCP, 48 (24%)study was a randomized controlled trial46 (level 4 evidence, level 4 were readmitted. These readmissions were due to recurrent biliaryevidence, and level 1b evidence, respectively).54 pancreatitis (n = 31), acute cholecystitis (n = 3), and biliary colics In the one randomized trial, Aboulian et al46 randomized be- (n = 14). ERCP protected against readmissions (10% vs 24%, P =tween cholecystectomy during the initial attack of pancreatitis versus 0.001).cholecystectomy after recovery but during index admission. On thebasis of our exclusion criteria, we included only the latter arm. Recurrent Pancreatitis After Cholecystectomy Only 2 of 9 studies (n = 157) reported follow-up afterBaseline Characteristics cholecystectomy.9,51 Cameron et al9 reported one case of recurrent The pooled data comprised 998 patients undergoing chole- biliary pancreatitis (2%), 223 days after cholecystectomy and Nebikercystectomy after mild biliary pancreatitis (range per study: 19–281 et al51 reported 1 case (1%) of recurrent biliary pancreatitis, 5 yearspatients). The definitions of mild biliary pancreatitis per study are after cholecystectomy. In both patients, a common bile duct stone wasshown in Table 1. In the 9 studies, 15 cohorts with different timing found. These patients suffered from mild pancreatitis and recoveredof cholecystectomy were described. One study described 2 different uneventfully. It is unclear whether these patients had undergone indexcohorts of patients undergoing interval cholecystectomy (Table 2).48 or interval cholecystectomy. The overall risk of recurrent pancreatitisRelevant baseline characteristics (ie, age and American Society of after cholecystectomy in the pooled data was therefore 2 (1%) of 157.Anesthesiologists (ASA) classification) were only reported in 2 stud-ies, including 263 patients (26%). A total of 483 (48%; described Assessment of Study Qualityin 6 different cohorts) of 998 patients, underwent cholecystectomy Table 4 shows the converted quality scores on a 0 to 10 scale.during index admission. In the remaining 9 cohorts, 515 (52%) of 998 The randomized trial scored high,46 5 studies scored moderate,47–51 2patients underwent interval cholecystectomy at a median of 40 days studies scored moderate to low,9,53 and 1 study scored low.52 Reasons(interquartile range: 19–58 days) after discharge. Six studies (645 for delay of surgery were reported in 338 (66%) of 515 patientspatients) reported on gender and age. The male–female ratio was 1:2, and were due to patient-related affairs (both patient-preferred delaywith a median age of 56 years (interquartile range: 53–60 years). and comorbidity, 34 patients, 10%), hospital-logistics (193 patients,Eight studies, including 13 different cohorts and 796 patients, re- 57%) and study design (111 patients, 33%). Two prospective cohortported on the number of patients who underwent preoperative ERCP: studies stated explicitly that cholecystectomy had intentionally been308 patients (39%). Not all 8 studies reported numbers on the use of postponed because of the study design.47,52endoscopic sphincterotomy implicitly. Four studies described the useof intraoperative cholangiography.9,46,48,50 DISCUSSION This first systematic review on the timing of cholecystectomyReadmission Before Cholecystectomy after mild biliary pancreatitis found high readmission rates (18%) Table 2 shows outcomes as reported in the included studies. for interval cholecystectomy. As morbidity was comparable betweenThe readmission rate between discharge and interval cholecystectomy index and interval cholecystectomy, it seems that cholecystectomywas 95/515 (18%). Of 515 patients, recurrent biliary pancreatitis oc- during index admission should be the preferred strategy for patientscurred in 43 (8%), acute cholecystitis in 17 (3%), and biliary colics with mild pancreatitis. However, as baseline characteristics were oftenrequiring readmission in 35 patients (7%). No new episodes of biliary not provided we cannot be sure whether the 2 groups are truly compa-events before cholecystectomy were reported in the patients under- rable. Selection bias might have played a role, for example, patientsgoing cholecystectomy during index admission (18% vs 0%, P < with more comorbidity might have undergone interval cholecystec-0.0001). Details about the severity of recurrent biliary pancreatitis tomy.could only be retrieved for 3 of 43 patients: 2 patients suffered from Why do clinicians perform interval cholecystectomy so often?severe recurrent biliary pancreatitis49 and 1 from mild recurrent bil- Lankisch et al12 sent a questionnaire to 190 German gastroenterolo-iary pancreatitis.48 gists and found that lack of operation room availability and budgetary restraints were the reason that only 23% of patients had undergoneOutcome of Cholecystectomy cholecystectomy during the initial hospital admission for mild biliary Eight studies, including 796 patients, reported on the conver- pancreatitis. These arguments have been challenged by a recent pa-sion rate. Overall, conversion to open cholecystectomy occurred in 58 per, concluding that cholecystectomy during index admission is bothpatients (7%), without differences between index and interval chole- feasible and cost neutral.10cystectomy. Major reasons for conversion were intra-abdominal adhe- For several decades surgeons have legitimated the choice forsions, however, no exact data about the distribution of the conversions interval cholecystectomy by the belief that cholecystectomy duringamong the 2 groups could be retrieved. One study did not distinguish index admission would be associated with difficult dissection duebetween laparoscopic and conventional cholecystectomy.47 Although to edema caused by pancreatitis, which could lead to more surgi-complications were described in all timing cohorts, not all studies cal complications and “unnecessary” conversions. In contrast to thisdescribed the number of patients with complications, but only the belief, in 107 patients with mild biliary pancreatitis, Sinha53 foundnumber of complications. For this reason, no overall complication that difficult dissection of Calot’s triangle occurred more frequentlyrate could be calculated. A total number of 116 different complica- in interval cholecystectomy as compared to index cholecystectomytions were described, including 3 common bile duct injuries, without (42% vs 12%, P < 0.001).mortality. Again, the exact type of complications and distribution Because the majority of patients apparently do not suffer fromamong the 2 groups could not be extracted from the included studies. recurrent biliary events necessitating readmission, one might ask “How detrimental are these recurrent biliary events? Why not onlyRole of Endoscopic Sphincterotomy/ERCP perform cholecystectomy in case of readmission?” Furthermore, al- Table 3 provides an overview of readmissions for biliary events though cholecystectomy is considered as a definitive treatment, stillin relation to the use of ERCP. Readmission after previous ERCP oc- 1% to 8.7% of patients suffer from recurrent biliary pancreatitis after862 | C 2012 Lippincott Williams & Wilkins Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  4. 4. Annals of Surgery r Volume 255, Number 5, May 2012 Timing of Cholecystectomy After Mild Biliary Pancreatitis TABLE 1. Characteristics of the Included Studies Study Country Year Definition of Mild Acute Biliary Pancreatitis Schachter et al52 Israel 2000 Acute abdominal pain with elevated serum and/or urine levels of amylase (>700 IU/L serum, normal 70–220; urine >1500 IU/L, normal <1000). Imaging confirmation of gallstones. Ranson ≤3. McCullough et al50 Canada 2003 Lipase >400 U/L. Radiographic confirmation of gallstones (US, CT, ERCP). No necrosis on CT, no ICU stay. Cameron and Goodman9 UK 2004 Acute upper abdominal pain, serum amylase >500 IU/l (normal 30–110). Gallstones demonstrated on US or ERCP. No description of a severity score. Griniatsos et al48 UK 2005 Generalized or upper abdominal pain and tenderness, elevation of serum amylase level more than three times the normal. Documented gallstones and absence of other factors known to cause acute pancreatitis. Modified Imrie score <3 within 48h after admission. Clarke et al47 USA 2008 Elevation of lipase 3 times or more the normal level. Gallstones on US. Ranson ≤3, no required emergent operative intervention for management of the biliopancreatic process. Ito et al49 USA 2008 Abdominal pain and tenderness, together with elevations in serum amylase and/or lipase concentration (at least 3 times the upper limit of normal). Documentation of gallstones or choledocholithiasis on imaging studies. No necrosis on CT scan. Nebiker et al51 Switzerland 2008 Acute abdominal pain with a threefold increase of serum amylase activity. Detection of gallstones on US, MRCP, or ERCP. Modified Ranson score ≤3, no necrosis on CT. Sinha53 India 2008 Serum amylase level more than 2 times the normal, increase ALT to 3 or more times the normal. US features of pancreatic edema and cholelithiasis with or without CBD stones. Ranson ≤4. Aboulian et al46 USA 2010 Upper abdominal pain, nausea, vomiting, epigastric tenderness, absence of ethanol use, elevated amylase level to at least twice the upper limit of normal. Imaging confirmation of gallstones. Ranson ≤3, clinical stability with admission to a non-monitored ward bed, absence of acute cholangitis, low suspicion for a retained CBD stone. ALT indicates alanine transaminase; CBD, common bile duct; CT computed topography; ICU, intensive care unit; MRCP, magnetic resonance cholan- giopancreatography; US, ultrasonography.cholecystectomy.13 Nevertheless, 4% to 50% of cases of recurrent bil- was to a large extent based on clinical arguments. There may alsoiary pancreatitis are severe, which might lead to mortality, although have been publication bias, as a result of underreporting by doctorfortunately not reported in this review.15,55 Because recurrent biliary or patient of biliary colics in general or as a reason for readmission.pancreatitis occurred in 8% of patients in the interval cholecystectomy Another limit of this systematic review is the fact that most includedgroup, we feel this is a strong argument in favor of cholecystectomy studies were of moderate to low methodological quality. Furthermore,during index admission. no adequate follow-up after cholecystectomy was reported in most It is generally accepted that patients with mild biliary pan- studies. Although follow-up is not necessarily needed in a compar-creatitis without signs of (potential) cholangitis do not benefit from ative study of preoperative readmissions for biliary events, it wouldendoscopic sphincterotomy.4 In this review, however, ERCP (or prob- give us a better insight of postoperative complications and recurrentably more correct: ERC) was performed in 39% of all patients, but biliary events after removal of the explicit data on the number of endoscopic sphincterotomies per- Only one randomized trial, by Aboulian et al, was includedformed during ERCP or the presence of cholangitis could be extracted in this review.46 The primary endpoint of this trial was length offrom the included studies. Recurrent biliary complications occurred hospital stay. The study was stopped at interim analysis for a one-in 10% of patients with and in 24% of patients without ERCP. This day shorter hospital stay after early cholecystectomy with no differ-difference was mainly due to a difference in recurrent biliary pancre- ence in secondary endpoints (eg, conversion rate, complication rateatitis (2% of patients with ERCP vs 16% of patients without ERCP). and mortality). We did not include the early group of this random-So, although ERCP prevents recurrent pancreatitis to a large extent, ized controlled trial, because we did not study cholecystectomy dur-it does not prevent against acute cholecystitis and biliary colics (8% ing pancreatitis but cholecystectomy after pancreatitis. There maywith ERCP vs 9% without ERCP). These numbers support the finding be risks involved with performing cholecystectomy in the first 48of a recent nonsystematic review; ERCP decreases the incidence of to 72 hours of pancreatitis, regardless of the clinical condition ofcommon bile duct stones-related complications, but will not prevent the patient.57 Of all patients with predicted mild pancreatitis, somegallbladder stones-related complications, like biliary colics and acute 15% of patients will progress to severe pancreatitis.58,59 Performing acholecystitis.56 Although in this review the percentage of patients cholecystectomy in patients with severe pancreatitis may be unsafe.5with preoperative ERCP seems to be very high, it is important to re- As in other studies,41–43 no life-threatening complications or mor-alize that with lower incidence of the protective ERCP the incidence tality were noted, but with only 25 patients in the early group theseof recurrent biliary events, especially biliary pancreatitis, could well numbers might have been too small to detect these complications.46have been even higher. Furthermore, the authors mainly included young Hispanic females, The results of the included studies are possibly flawed by se- a population that may be of lower risk of complications than manylection bias, because the choice for index or interval cholecystectomy populations with mild pancreatitis worldwide.60C 2012 Lippincott Williams & Wilkins | 863 Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited.
  5. 5. van Baal et al TABLE 2. Patient Outcomes of the Included Studies 864 | Readmissions for Recurrent Conversion to Open Time Between Discharge and Biliary Events (%) (N = Biliary Cholecystectomy Number of Patients Cholecystectomy (Range/±SD) (d) Pancreatitis, Cholecystitis, Colics) (%) Complications Index Interval Index Index Index Interval Index Interval Reasons for Delay Study cholec. cholec. cholec. Interval cholec. cholec. Interval cholec. cholec. cholec. cholec. cholec. in Surgery Schachter et al52 — 19 — >56 — 0 – 2 (11%) — 0 All study-related McCullough et al50 74 90 0 Mean 40 (±69) 0 18 (20%) (3,5,10) 9 (12%) 8 (9%) 11 16 All hospital-related Cameron and — 58 — Mean 93 Median 68 (5–720) — 11 (19%) (4,3,4) – 7 (12%) — 0 NR Goodman9 Griniatsos et al∗48 — 20 — Median 14 (7–14) — 0 — 0 — 1 All hospital-related Griniatsos et al∗48 – 24 — Median 60 (47–91) – 1 (4%) (1,0,0) – 0 — 1 16 hospital-related, 4 delay of clinical improvement, 4 severe comorbidity Clarke et al47 110 92 0 Mean 23 (±10) 0 8 (9%) (7,1,0) NR NR 4 5 All study-related Ito et al49 162 119 0 Median 45 (4–436) 0 39 (33%) (16,6,17) 20 (12%) 8 (7%) 37 34 NR Nebiker et al51 32 67 0 >14 0 15 (22%) (9,2,4) 2 (6%) 2 (3%) 2 5 All hospital-related Sinha53 81 26 0 >42 0 3 (12%) (3,0,0) 0 0 0 0 All patient-related Aboulian et al46 24 — 0 — 0 — 0 — 0 — — Total 483 515 0 Median 40 0 95 (18%) (43,17,35) 31 (9%)† 27 (6%) 17 (4%) 29 (6%) — ∗ In one study, 2 different groups of interval cholecystectomy were described. †Percentages only calculated for the studies that reported this endpoint. C NR indicates not reported; SD, standard deviation.Copyright © 2012 Lippincott Williams & Wilkins. Unauthorized reproduction of this article is prohibited. 2012 Lippincott Williams & Wilkins Annals of Surgery r Volume 255, Number 5, May 2012
  6. 6. Annals of Surgery r Volume 255, Number 5, May 2012 Timing of Cholecystectomy After Mild Biliary Pancreatitis TABLE 3. Patient Outcomes in Patients With or Without ERCP Undergoing Delayed Cholecystectomy Readmissions After Readmissions Without Previous ERCP/ES Previous ERCP/ES (Biliary Pancreatitis, (Biliary Pancreatitis, Study N ERCP/ES (%) Cholecystitis, Colics) Cholecystitis, Colics) Schachter et al52 19 100% 0 0 McCullough et al50 90 63% NR NR Cameron and Goodman9 58 64% NR (0,NR,NR) ≥4 (4,NR,NR) Griniatsos et al∗48 20 0% 0 0 Griniatsos et al∗48 24 0% 0 1 (4%) (1,0,0) Clarke et al47 92 NR NR NR Ito et al49 119 47% 14 (12%) (2,5,7) 25 (21%) (4,1,10) Nebiker et al51 67 36% 0 15 (22%) (9,2,4) Sinha53 26 0% 0 3 (12%) (3,0,0) Total 515 40% 14 (10%) (2,5,7) ≥48 (24%) (31,3,14) ∗ In one study, 2 different groups of interval cholecystectomy were described. ES indicates endoscopic sphincterotomy; NR, not reported. 6. Working Party of the British Society of Gastroenterology; Association ofTABLE 4. Quality Assessment of the Included Studies With 2 Surgeons of Great Britain and Ireland; Pancreatic Society of Great BritainDifferent Scoring Lists and Ireland; Association of Upper GI Surgeons of Great Britain and Ireland. UK guidelines for the management of acute pancreatitis. Gut. 2005;54(suppl 3):iii1–iii9. Checklist for (Non-) 7. Forsmark CE, Baillie J. AGA Institute technical review on acute pancreatitis.Study MINORS Checklist∗ Randomized Trials∗ Gastroenterology. 2007;132:2022–2044.Schachter et al52 3.8 3.7 8. Uhl W, Warshaw A, Imrie C, et al. IAP Guidelines for the Surgical ManagementMcCullough et al50 6.7 5.9 of Acute Pancreatitis. Pancreatology. 2002;2:565–573.Cameron and Goodman9 5.6 5.9 9. Cameron DR, Goodman AJ. Delayed cholecystectomy for gallstone pancreati-Griniatsos et al48 6.7 6.7 tis: re-admissions and outcomes. Ann R Coll Surg Engl. 2004;86:358–362.Clarke et al47 6.7 6.7 10. Monkhouse SJ, Court EL, Dash I, et al. Two-week target for laparoscopicIto et al49 7.5 6.3 cholecystectomy following gallstone pancreatitis is achievable and cost neutral. Br J Surg. 2009;96:751–755.Nebiker51 7.5 6.7Sinha53 6.3 5.2 11. Sargen K, Kingsnorth AN. Management of gallstone pancreatitis: effects of deviation from clinical guidelines. JOP. 2001;2:317–322.Aboulian et al46 — 8.9 12. Lankisch PG, Weber-Dany B, Lerch MM. Clinical perspectives in pancreatol- ∗ ogy: compliance with acute pancreatitis guidelines in Germany. Pancreatology. All scores are 0–10, with 10 reflecting the highest methodological score. 2005;5:591–593. 13. Pezzilli R, Uomo G, Gabbrielli A, et al. A prospective multicentre sur- vey on the treatment of acute pancreatitis in Italy. Dig Liver Dis. 2007;39: Although interval cholecystectomy is clearly associated with 838– undesirable high rate of readmissions, the included studies were of 14. Nguyen GC, Boudreau H, Jagannath SB. Hospital volume as a predictor forinsufficient quality to exclude selection bias. Therefore, randomized undergoing cholecystectomy after admission for acute biliary pancreatitis. Pan- creas. 2010;39:e42–e47.controlled studies should confirm the efficacy and safety of cholecys- 15. Hernandez V, Pascual I, Almela P, et al. Recurrence of acute gallstone pan-tectomy during index admission for mild biliary pancreatitis. creatitis and relationship with cholecystectomy or endoscopic sphincterotomy. Am J Gastroenterol. 2004;99:2417–2423. ACKNOWLEDGMENTS 16. Liberati A, Altman DG, Tetzlaff J, et al. The PRISMA statement for report- The authors thank the following persons for providing ad- ing systematic reviews and meta-analyses of studies that evaluate health careditional data on their studies: Rodney Mason, Rajeev Sinha, John interventions: explanation and elaboration. PLoS Med. 2009;6:e1000100.Griniatsos, Daniel Frey, and Pinhas Schachter. 17. Bradley EL, III. 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