Early Cholecystectomy Advocated for Biliary Pancreatitis Early Versus Delayed Cholecystectomy in Patients With Biliary Acute Pancreatitis

Background: Biliary pancreatitis is caused by transient obstruction of the pancreatic duct by a gallstone. Most patients pass these stones spontaneously. A cholecystectomy resolves future recurrences. Objective: To define the optimal timing of laparoscopic cholecystectomy after biliary pancreatitis. Design: Retrospective analysis of the records of patients who had a laparoscopic cholecystectomy for biliary pancreatitis. Participants: 99 patients had acute abdominal pain, serum amylase elevation, and confirmed gallstones. Methods: Patients were divided into an early (n=32) and late (n=67) group based on whether the gallbladder was removed within 2 weeks admission or 2 weeks after admission. Patients with elevated bilirubin and common duct stones demonstrated on magnetic resonance cholangiopancreatography (MRCP) or ultrasound had endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy performed. The primary end point was gallstone-related complications including biliary colic, cholecystitis, cholangitis, or recurrent pancreatitis. Interventions: ERCP was performed in 5 early patients and 24 late patients. Conversion to an open cholecystectomy was necessary in 4 early and 2 late patients. Results: 15 late cholecystectomy patients had recurrent symptoms before their cholecystectomy. Nine of these developed recurrent pancreatitis, 4 had biliary colic, and 2 had acute cholecystitis. None of the early patients had recurrent symptoms. Complications after cholecystectomy in either group were similar, and no one died in either group. Overall, 15% of patients had biliary stones extracted from the common bile duct. Conclusions: Delaying cholecystectomy for 2 weeks after an episode of biliary pancreatitis is associated with an increase in recurrent pancreatitis. Reviewer's Comments: Acosta's paper from 1974 noting gallstones as the etiology of biliary pancreatitis is the first reference in this paper. The timing of cholecystectomy and the need to clear the common bile duct are the discussion points. Routine clearance of the bile duct with ERCP has fallen out of favor as most stones will pass. A patient with cholangitis falls out of this recommendation and needs drainage of the bile duct emergently. "Early" is described in various ways, and these authors chose 2 weeks. I believe the timing should even be faster. Once the abdominal pain subsides and the patients are nontender without jaundice, we perform a cholecystectomy. Routine cholangiography is not used; if persistent symptoms exist postoperatively, ERCP is performed. The finding that only 15% of these patients had stones extracted from the biliary ducts emphasizes that routine ERCP has a questionable risk-to-benefit ratio. Additionally, the number of these stones that would pass spontaneously is unknown. Whether routine MRCP can identify patients who should have ERCP preoperatively is unknown. We believe our approach is safe and cost-effective. Most of our patients are have their surgery within 1 week of admission to the hospital. Early operation is good for these patients. (Reviewer-John A. Weigelt, MD).