Optimal timing of cholecystectomy after necrotising biliary pancreatitis

Abstract

ObjectiveFollowing an episode of acute biliary pancreatitis, cholecystectomy is advised to prevent recurrent biliary events. There is limited evidence regarding the optimal timing and safety of cholecystectomy in patients with necrotising biliary pancreatitis.DesignA post hoc analysis of a multicentre prospective cohort. Patients with biliary pancreatitis and a CT severity score of three or more were included in 27 Dutch hospitals between 2005 and 2014. Primary outcome was the optimal timing of cholecystectomy in patients with necrotising biliary pancreatitis, defined as: the optimal point in time with the lowest risk of recurrent biliary events and the lowest risk of complications of cholecystectomy. Secondary outcomes were the number of recurrent biliary events, periprocedural complications of cholecystectomy and the protective value of endoscopic sphincterotomy for the recurrence of biliary events.ResultsOverall, 248 patients were included in the analysis. Cholecystectomy was performed in 191 patients (77%) at a median of 103 days (P25–P75: 46–222) after discharge. Infected necrosis after cholecystectomy occurred in four (2%) patients with persistent peripancreatic collections. Before cholecystectomy, 66 patients (27%) developed biliary events. The risk of overall recurrent biliary events prior to cholecystectomy was significantly lower before 10 weeks after discharge (risk ratio 0.49 (95% CI 0.27 to 0.90); p=0.02). The risk of recurrent pancreatitis before cholecystectomy was significantly lower before 8 weeks after discharge (risk ratio 0.14 (95% CI 0.02 to 1.0); p=0.02). The complication rate of cholecystectomy did not decrease over time. Endoscopic sphincterotomy did not reduce the risk of recurrent biliary events (OR 1.40 (95% CI 0.74 to 2.83)).ConclusionThe optimal timing of cholecystectomy after necrotising biliary pancreatitis, in the absence of peripancreatic collections, is within 8 weeks after discharge.

Patient selection for urgent endoscopic retrograde cholangio-pancreatography by endoscopic ultrasound in predicted severe acute biliary pancreatitis (APEC-2): a multicentre prospective study

“…Readmission for recurrent biliary events, especially recurrent biliary pancreatitis, was more frequent in the conservative treatment group compared with the urgent EUS-guided ERCP group. Cholecystectomy is the most effective strategy to prevent recurrent biliary events after ABP, both in the case of a mild and a severe disease course 19 20. In case of a mild disease course, cholecystectomy should be performed during the same admission.…”

Update on the management of acute pancreatitis

“…The standard for mild biliary pancreatitis is a same-admission cholecystectomy, but there is no consensus regarding the optimal timing of cholecystectomy for patients with necrotizing pancreatitis. A large retrospective analysis shows that cholecystectomy was performed at a median of over 3 months following discharge [36 ▪ ]. Early (<8 weeks) cholecystectomy might reduce biliary recurrences, however due to the retrospective nature there remains a strong need for a (randomized) trial.…”

Contemporary Surgical Management of Pancreatic Necrosis

“…In patients managed with operative transgastric necrosectomy, as described above, this is still a viable option. In patients managed with a step-up approach, there is a substantial risk of gallstone-related complications in the delay before cholecystectomy if it is deferred until resolution of necrosis, as high as 20% in recent studies . However, there is no evidence-based consensus on the optimal timing of cholecystectomy in step-up patients, and better evidence-based patient benchmarks are needed to determine this.…”