Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

Self Cite

COMMENT & RESPONSEIn Reply We appreciate the valuable correspondence from Robertson et al and Zhu and Wei regarding our article, which has allowed us to further clarify the strengths and limitations of our findings.The primary goal of cholecystectomy in acute biliary pancreatitis (ABP) is to prevent recurrent attacks. While early cholecystectomy (EC) is established as safe for mild ABP, its safety for moderately severe and severe ABP lacks robust evidence. 1 Our study is a post hoc analysis of the MANCTRA-1, originally designed to assess guideline compliance and related outcomes. 2 Our analysis reveals that EC in patients with moderately severe and severe ABP should be approached cautiously.As noted by our colleagues, significant differences in baseline characteristics between the study and control groups were apparent. These differences were highlighted through the analysis of specific patient-related comorbidities, including cardiac, pulmonary, kidney, or endocrinological disorders, and composite outcomes such as the Charlson Comorbidity Index. Given the intrinsic relationship between these differences and the nature of ABP, achieving perfectly balanced study and control groups with sufficient statistical power is unlikely. To address these limitations, we conducted subgroup and adjusted statistical analyses using multivariable regression models.We agree that, despite the inclusion of several international centers, our cohort may be inconsistent with earlier reports on acute pancreatitis, with only 108 patients having moderately severe or severe ABP. 3 A possible explanation may be found in the fact that we enrolled only patients with ABP. Another important limitation also highlighted in the article is that some EC procedures may have coincided with other interventional procedures in patients with unresolved organ dysfunction, making it impossible to draw firm conclusions about the specific cause of death in those cases. Therefore, we concur that the nature of the study does not permit us to make strong definitive statements regarding the causal relationship between EC and postoperative complications.Nevertheless, it is important to note that patients with moderately severe and severe ABP exhibited not only i n c re a s e d m o r b i d it y a n d m o r t a l it y b u t a l s o m o re cholecystectomy-related complications, such as bile leakage (2.4%), when compared with patients with mild ABP. This indicated an elevated postoperative risk for the study group. Additionally, we conducted subgroup analyses for patients with both moderately severe and severe ABP and adjusted analyses aimed at providing insights into patients at higher risk of complications. These analyses indicated that patients with more complex cases and a pronounced inflammatory

mentioning

confidence: 99%

Optimal Timing of Cholecystectomy for Severe Acute Pancreatitis and Understanding Complications and Comorbidities—Reply

Di Martino,

Ielpo,

Podda

2024

Self Cite

“…In the Original Investigation titled “Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis,” published on August 23, 2023, the heading for the third column in Table 2 was erroneously written as “Moderately severe ABP only”; the correct heading is “Severe ABP only.” Also, the percentage of patients with postcholecystectomy mortality was incorrectly reported as 15.6%; the correct value is 15.5%. This article has been corrected …”

mentioning

confidence: 99%

Errors in Results and Table 2

2024

In the Original Investigation titled "Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis," 1 published on August 23, 2023, the heading for the third column in Table 2 was erroneously written as "Moderately severe ABP only"; the correct heading is "Severe ABP only." Also, the percentage of patients with postcholecystectomy mortality was incorrectly reported as 15.6%; the correct value is 15.5%. This article has been corrected. 1

“…To the Editor We read with interest the article by Di Martino and colleagues . The timing of cholecystectomy after admission with moderately severe or severe acute biliary pancreatitis remains unclear, and the authors are to be congratulated for presenting such a large multinational study.…”

mentioning

confidence: 99%

Optimal Timing of Cholecystectomy for Severe Acute Pancreatitis and Understanding Complications and Comorbidities

Robertson,

Dennison,

Pandanaboyana

2024

To the Editor We read with interest the article by Di Martino and colleagues. 1 The timing of cholecystectomy after admission with moderately severe or severe acute biliary pancreatitis remains unclear, and the authors are to be congratulated for presenting such a large multinational study.The authors have shown that patients admitted with moderately severe or severe pancreatitis who undergo cholecystectomy within 14 days of admission have a significantly higher risk of morbidity (30 patients [30.3%] vs 57 patients [5.5%]; P < .001) and mortality (16 patients [15.6%] vs 0 patients; P < .001). However, these results need to be interpreted with caution.First, of the 3696 patients, data for only 108 patients (2.9%) with moderately severe or severe pancreatitis were captured. This percentage is much lower than the published literature, and reasons for this are not identified. While it is likely that these 2 patient cohorts were combined to provide sufficient numbers for analysis, this approach is fundamentally flawed. They are 2 distinct patient groups. A UK study demonstrated that the mortality rates differ significantly (8% for moderately severe vs 25.4% for severe). 2 In addition, the authors did not report on data validation, and with centers from a number of countries contributing patients, this is an important consideration.Second, no data have been provided from this study to demonstrate whether or not organ dysfunction had resolved by the time of cholecystectomy or the number of patients in the moderately severe group. The absence of these confounding variables means that morbidity and mortality rates between the groups cannot be compared as they may simply reflect disease severity, and early intervention in severe pancreatitis is associated with poorer outcomes. 3,4 Further data that would be helpful are those identifying the cause of death in patients with early cholecystectomy and the rate of conversion to an open procedure.The conclusion that cholecystectomy within 14 days of admission should be considered carefully in this patient group is not confirmed from these data. It is also not possible to con-clude that older, more fragile patients with complications should not be considered for early cholecystectomy when 991 patients were excluded from the analysis because of age or comorbidity. Our recent experience suggests that patients with severe acute pancreatitis remain sarcopenic even 12 months postdischarge, 5 and any surgical intervention will be poorly tolerated. The optimal timing in patients with moderately severe acute pancreatitis remains to be elucidated, but earlier cholecystectomy may be warranted, and further longitudinal studies are required.