Patients with presumed mild gallstone-related acute pancreatitis who underwent cholecystectomy during their index hospitalization had lower rates of recurrent pancreatitis and other gallstone-related complications than those treated with endoscopic retrograde cholangiopancreatography alone or no intervention.
Researchers used the Swedish Pancreatitis (SwePan) registry to evaluate 9,593 adults hospitalized with a first episode of gallstone-related acute pancreatitis between 2006 and 2019 who had hospital stays of 10 days or less, which the investigators used as a pragmatic surrogate for disease severity. Patients were grouped according to index-admission management: cholecystectomy with or without endoscopic retrograde cholangiopancreatography (ERCP), ERCP alone, or no intervention. Follow-up began the day following hospital discharge. The primary outcome was recurrent acute pancreatitis, and the secondary outcome was other gallstone-related complications, including acute cholecystitis and choledocholithiasis. Analyses accounted for death as a competing event and adjusted for demographic characteristics, calendar period, socioeconomic factors, and comorbidities.
Among the study population, 29% underwent same-admission cholecystectomy, 17% underwent ERCP alone, and 54% received no intervention during the index hospitalization. Recurrent acute pancreatitis occurred in 3% of patients who underwent cholecystectomy, compared with 5% of those treated with ERCP alone and 18% of those who received no intervention. Other gallstone-related complications occurred in 2%, 20%, and 16% of patients, respectively.
Compared with same-admission cholecystectomy, no intervention was associated with an approximately sixfold higher risk of recurrent pancreatitis during follow-up. ERCP alone was associated with a modestly higher overall risk of recurrence, driven primarily by events within the first 2 weeks following discharge. Beyond that period, the investigators found no evidence of a higher recurrence risk with ERCP alone than with cholecystectomy, and beyond 1 year, ERCP alone was associated with a lower recurrence risk, although the absolute long-term risk was low in both groups. Biliary complications, however, remained substantially more common among patients treated with ERCP alone.
Nearly one-half of all recurrent pancreatitis episodes occurred within the first month following discharge. Patients who underwent elective cholecystectomy after discharge also experienced more recurrent pancreatitis than those who underwent surgery during the index admission. Prespecified subgroup analyses found no evidence that the associations differed according to age, sex, hospital length of stay, or baseline comorbidity status.
The researchers noted that ERCP alone may remain an appropriate option for selected patients who are not candidates for surgery. Although long-term recurrence of pancreatitis was low following ERCP alone, patients remained at increased risk for other gallstone-related complications because the gallbladder was left in place. More than one-half of patients in the cohort did not undergo cholecystectomy or ERCP during their initial hospitalization, despite guideline recommendations supporting same-admission cholecystectomy for presumed mild gallstone-related acute pancreatitis.
The study was limited by its observational design, leaving the possibility of residual confounding and selection bias. Patients treated with ERCP alone were generally older and had more comorbidities than those who underwent cholecystectomy, and the registry lacked detailed clinical information on disease severity, imaging findings, laboratory values, smoking, alcohol use, and procedural indications. In addition, the investigators excluded patients with presumed severe pancreatitis using hospital length of stay as a surrogate, although some patients with moderately severe or severe pancreatitis may still have been included.
Overall, the findings support current guideline recommendations favoring same-admission cholecystectomy for eligible patients with presumed mild gallstone-related acute pancreatitis while suggesting that ERCP alone may be a reasonable alternative for patients who are not suitable surgical candidates, although it does not appear to provide comparable protection against other gallstone-related complications.
“Same-admission cholecystectomy should be prioritized for eligible patients and system-level barriers to timely surgery identified and improved,” wrote lead study author Daniel Selin, MD, of Karolinska Institutet, and colleagues.
Disclosures: Drs. Valente and Arnelo reported consulting relationships with Boston Scientific. Dr. Arnelo also reported grants from the Swedish Cancer and Allergy Foundation, and Dr. Ljung reported employment with the Swedish Medical Products Agency.
Source: JAMA Surgery
