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Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis
Marcello Di Martino1, Benedetto Ielpo2, Francesco Pata3,4
1Division of Hepatobiliary and Liver Transplantation Surgery, A.O.R.N. Cardarelli, Naples, Italy.
Insights
Early cholecystectomy (EC) in severe acute biliary pancreatitis (ABP) increases mortality and morbidity. Careful consideration is advised for EC in these patients, especially those with severe complications or comorbidities.
Area of Science:
- Gastroenterology
- Surgical Outcomes
- Clinical Epidemiology
Background:
- The optimal timing for cholecystectomy in acute biliary pancreatitis (ABP) remains debated, particularly for moderately severe and severe cases.
- Evidence-based guidelines exist, but real-world adherence and outcomes require further investigation.
Purpose of the Study:
- To evaluate the outcomes of early cholecystectomy (EC) compared to delayed cholecystectomy (DC) in patients diagnosed with moderately severe and severe acute biliary pancreatitis (ABP).
Main Methods:
- Retrospective cohort study utilizing the MANCTRA-1 dataset, including 3696 patients with ABP who underwent cholecystectomy.
- Analysis involved univariable and multivariable logistic regression to identify prognostic factors for mortality and morbidity.
- EC was defined as cholecystectomy within 14 days of admission.
Main Results:
- Early cholecystectomy (EC) was associated with significantly higher postoperative mortality (1.4% vs. 0.1%) and morbidity (7.7% vs. 3.7%) compared to delayed cholecystectomy (DC).
- In patients with moderately severe to severe ABP, EC showed increased mortality (15.6% vs. 1.2%) and morbidity (30.3% vs. 10.3%) versus DC.
- Patient age and American Society of Anesthesiologists score were linked to mortality; severe ABP complications significantly increased both mortality and morbidity.
Conclusions:
- Early cholecystectomy (EC) in patients with moderately severe and severe acute biliary pancreatitis (ABP) is linked to increased postoperative risks.
- EC should be approached with caution in this patient group, particularly for older individuals or those with severe complications.
- Delayed cholecystectomy (DC) may offer a safer alternative for managing severe ABP.
Importance:
Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue.
Objective:
To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP.
Design, Settings, And Participants:
This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023.
Main Outcomes:
Mortality and morbidity after EC.
Results:
Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P < .001) and morbidity (7.7% vs 3.7%, P < .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P < .001), morbidity (30 [30.3%] vs 57 [5.5%], P < .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P < .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P < .001), morbidity (30 [30.3%] vs 17 [10.3%], P < .001), and infections (12 [14.6%] vs 2 [1.3%], P < .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003).
Conclusions And Relevance:
This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC.
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