Gallstone pancreatitis: does discharge and readmission for cholecystectomy affect outcome?

The risk of recurrent pancreatitis after first episode of acute pancreatitis in relation to etiology and severity of disease: A systematic review, meta-analysis and meta-regression analysis

BACKGROUND AND AIM

The study aims to determine and quantify the stratified risk of recurrent pancreatitis (RP) after the first episode of acute pancreatitis in relation to etiology and severity of disease.

METHODS

A systematic review and meta-analysis in compliance with PRISMA statement standards was conducted. A search of electronic information sources was conducted to identify all studies investigating the risk of RP after the first episode of acute pancreatitis. Proportion meta-analysis models using random effects were constructed to calculate the weighted summary risks of RP. Meta-regression was performed to evaluate the effect of different variables on the pooled outcomes.

RESULTS

Analysis of 57,815 patients from 42 studies showed that the risk of RP after first episode was 19.8% (95% confidence interval [CI] 17.5-22.1%). The risk of RP was 11.9% (10.2-13.5%) after gallstone pancreatitis, 28.7% (23.5-33.9%) after alcohol-induced pancreatitis, 30.3% (15.5-45.0%) after hyperlipidemia-induced pancreatitis, 38.1% (28.9-47.3%) after autoimmune pancreatitis, 15.1% (11.6-18.6%) after idiopathic pancreatitis, 22.0% (16.9-27.1%) after mild pancreatitis, 23.9% (12.9-34.8%) after moderate pancreatitis, 21.6% (14.6-28.7%) after severe pancreatitis, and 6.6% (4.1-9.2%) after cholecystectomy following gallstone pancreatitis. Meta-regression confirmed that the results were not affected by the year of study (P = 0.541), sample size (P = 0.064), length of follow-up (P = 0.348), and age of patients (P = 0.138) in the included studies.

CONCLUSIONS

The risk of RP after the first episode of acute pancreatitis seems to be affected by the etiology of pancreatitis but not the severity of disease. The risks seem to be higher in patients with autoimmune pancreatitis, hyperlipidemia-induced pancreatitis, and alcohol-induced pancreatitis and lower in patients with gallstone pancreatitis and idiopathic pancreatitis.

Long-term outcome of patients with biliary pancreatitis not undergoing cholecystectomy. A retrospective study

BACKGROUND AND OBJECTIVE

Most acute pancreatitis are of biliary origin and undergoing a cholecystectomy is recommended to prevent recurrence. However, some patients will never be referred to surgery. We reviewed the long-term follow-up of these group of patients Methods All cases of biliary pancreatitis presented from January 2015 to December 2017 that did not receive a cholecystectomy were analyzed. Epidemiologic data and Charlson comorbidity Index (CCI) were recorded. Recurrent episodes of pancreatitis or biliary events and mortality during the follow-up period was recorded. Results A total of 104 patients were included in the study (30.4% of all biliary pancreatitis). Median age was 82 years (range 27-96). Average CCI was 5 (range 0-18). The median follow-up period was 37 months (range 1-70). A total of 41 patients (39.4%) had gallstone-related complications. Twenty-three patients (22,1%) had recurrent pancreatitis and 34 (32,7%) developed biliary events. Decease occurred in 25 patients during follow-up (24%) but only 6 (5,8%) were due to gallstone-related complications. Non-related mortality was 15.5% in patients who refused surgery and 25% if high comorbidity patients.

CONCLUSION

Patients that are not cholecystectomized are at high risk for biliary event and pancreatitis recurrence. Conservative treatment and surgical abstention should be individualized and reserved to high comorbid patients with short life expectancy.

The optimal timing of laparoscopic cholecystectomy in patients with mild gallstone pancreatitis: A meta-analysis

BACKGROUND

The optimal timing of laparoscopic cholecystectomy (LC) in patients with mild acute gallstone pancreatitis (MAGP) is controversial. The aim of this study was to systematically evaluate and compare the safety and efficacy of early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC) in patients with MAGP.

METHODS

A strict search was conducted of the electronic databases, including PubMed, MEDLINE Embase, the ISI Web of Science, and Cochrane Library for all relevant English literature and RevMan5.3 software for statistical analysis was used.

RESULTS

A total of 19 studies comprising 2639 patients were included. There was no significant difference in intraoperative complications [risk ratio (RR) = 1.46; 95% confidence interval (CI) = 0.88-2.41; P = .14)], postoperative complications (RR = 0.81; 95% CI = 0.58-1.14; P = .23), rate of conversion to open cholecystectomy (RR = 1.00; 95% CI = 0.75-1.33; P = .99), operative time (MD = 1.60; 95% CI = -1.36-4.56; P = .29), and rate of readmission (RR = 0.63; 95% CI = 0.19-2.10; P = .45) between the ELC and DLC groups. However, the ELC group was significantly correlated with lower length of hospital stay (MD = -2.01; 95% CI = -3.15 to -0.87; P = .0006), fewer gallstone-related events rates (RR = 0.17; 95% CI = 0.07-0.44; P = .0003), and lower endoscopic retrograde cholangiopancreatography (ERCP) usage (RR = 0.83; 95% CI = 0.71-0.97; P = .02) compared with the DLC group.

CONCLUSION

Early laparoscopic cholecystectomy is safe and effective for patients with MAGP, but the indications and contraindications must be strictly controlled.

Same-admission versus delayed cholecystectomy for mild acute biliary pancreatitis: a systematic review and meta-analysis

BACKGROUND

The timing of laparoscopic cholecystectomy (LC) performed after the mild acute biliary pancreatitis (MABP) is still controversial. We conducted a review to compare same-admission laparoscopic cholecystectomy (SA-LC) and delayed laparoscopic cholecystectomy (DLC) after mild acute biliary pancreatitis (MABP).

METHODS

We systematically searched several databases (PubMed, EMBASE, Web of Science, and the Cochrane Library) for relevant trials published from 1 January 1992 to 1 June 2018. Human prospective or retrospective studies that compared SA-LC and DLC after MABP were included. The measured outcomes were the rate of conversion to open cholecystectomy (COC), rate of postoperative complications, rate of biliary-related complications, operative time (OT), and length of stay (LOS). The meta-analysis was performed using Review Manager 5.3 software (The Cochrane Collaboration, Oxford, United Kingdom).

RESULTS

This meta-analysis involved 1833 patients from 4 randomized controlled trials and 7 retrospective studies. No significant differences were found in the rate of COC (risk ratio [RR] = 1.24; 95% confidence interval [CI], 0.78-1.97; p = 0.36), rate of postoperative complications (RR = 1.06; 95% CI, 0.67-1.69; p = 0.80), rate of biliary-related complications (RR = 1.28; 95% CI, 0.42-3.86; p = 0.66), or OT (RR = 1.57; 95% CI, - 1.58-4.72; p = 0.33) between the SA-LC and DLC groups. The LOS was significantly longer in the DLC group (RR = - 2.08; 95% CI, - 3.17 to - 0.99; p = 0.0002). Unexpectedly, the subgroup analysis showed no significant difference in LOS according to the Atlanta classification (RR = - 0.40; 95% CI, - 0.80-0.01; p = 0.05). The gallstone-related complications during the waiting time in the DLC group included gall colic, recurrent pancreatitis, acute cholecystitis, jaundice, and acute cholangitis (total, 25.39%).

CONCLUSION

This study confirms the safety of SA-LC, which could shorten the LOS. However, the study findings have a number of important implications for future practice.

Timing of Laparoscopic Cholecystectomy After Mild Biliary Pancreatitis: A Systematic Review and Meta-Analysis

AIM

To compare the safety of cholecystectomy in early laparoscopic cholecystectomy (ELC) and delayed laparoscopic cholecystectomy (DLC).

METHODS

We systematically searched PubMed, EMBASE, and Cochrane Library for studies that were published from January 1992 to March 2017. We included studies on patients with mild biliary pancreatitis and that reported the timing of cholecystectomy and the number of complications, readmissions, and conversion to open cholecystectomy. Moreover, we assessed the quality and bias risks of the included studies.

RESULTS

After screening 4651 studies, we included 3 randomized clinical trials and 10 retrospective studies. The included studies described 2291 patients, of whom 1141 (49.8%) underwent ELC and 1150 (50.2%) underwent DLC. The reported rate of complications for ELC (6.8%) was lower than that for DLC (13.45%). The reported rate of readmission for ELC was lower than that for DLC. The length of hospital stay was longer with DLC than with ELC. ELC and DLC did not have significantly different rates of conversion to open cholecystectomy and duration of surgery.

CONCLUSION

This meta-analysis provides evidence that ELC is better than DLC in many aspects for acute mild pancreatitis patients undergoing laparoscopic cholecystectomy. ELC associated with few complications and readmissions, as well as a short length of hospital stay.

Management of acute pancreatitis

Acute pancreatitis (AP) is a common medical condition with extensive morbidity and mortality. Approximately 210,000 Americans are hospitalized each year; and 5% of patients with AP will die. It is also an expensive condition, costing 2.6 billion dollars (United States) in 2009 alone. Moreover, the incidence is increasing - the National Hospital Discharge Survey showed hospitalizations increased from 78 per 100,000 in 2007 to 90 per 100,000 just three years later in 2010. There is no proven pharmacologic entity to treat the inflammatory response associated with acute pancreatitis; supportive care with IV fluids, bowel rest and pain control are the mainstays of therapy. Recently, new developments to help increase survival and minimize morbidity with several key interventions have been investigated. This summary highlights new studies and meta-analyses to provide current opinion on treatment of this morbid condition.

Treatment strategy for gallstone pancreatitis and the timing of cholecystectomy

AIM: To reviewed the literature and evaluated the scope and timing of the application of endoscopic retrograde cholangiopancreatography (ERCP)/endoscopic sphincterotomy (ES) and cholecystectomy.

METHODS: A pooled odds ratio (OR) and a pooled mean difference with the 95%CI were used to assess the enumeration data of included studies. A pooled weighted mean difference (WMD) and a pooled mean difference with the 95%CI were used to assess the measurement data of included studies. Statistical heterogeneity was tested with the χ² test. According to forest plots, heterogeneity was not significant, so the fixed effect model was adopted. The significance of the pooled OR was determined by the Z test and statistical significance was considered at P < 0.05.

RESULTS: Data were collected from two studies (353 patients, 142 in the early cholecystectomy group and 211 in the delayed cholecystectomy group) regarding the length of hospital stay [The WMD was -2.87 (95%CI: -3.36--2.39, P < 0.01). Data were collected from four studies (618 patients, 211 in the early cholecystectomy group and 408 in the delayed cholecystectomy group) regarding perioperative complications (OR = 0.94, 95%CI: 0.41-2.12, P > 0.05). Data were collected from four studies (618 patients, 211 in the early cholecystectomy group and 408 in the delayed cholecystectomy group) on the number of patients who underwent ERCP± ES postoperatively (OR = 0.80, 95%CI: 0.45-1.41, P > 0.05).

CONCLUSION: Cholecystectomy offers better protection than ES against further bouts of pancreatitis in patients with gallstone pancreatitis, although ES is an acceptable alternative.

The "golden hours" of management in acute pancreatitis

In the past decade, a significant amount of active and enthusiastic research has changed the way we treat acute pancreatitis (AP) within the first 24 hours of presentation. We highlight the importance of rapid initiation of treatment to help prevent the considerable morbidity and mortality that can occur when interventions are delayed. We review recent data that validate simple and accurate tools for prognostication of AP to replace the older, more tedious methods that relied on numerous factors and required up to 48 hours to complete. Additionally, we aim to provide evidence-based guidelines and end points for fluid resuscitation. Finally, we hope to bring clarification to two previously controversial topics in AP treatment: the use of prophylactic antibiotics and early endoscopic retrograde cholangiopancreatography.

Timing of cholecystectomy after mild biliary pancreatitis

Background

The aim of the study was to evaluate recurrent biliary events as a consequence of delay in cholecystectomy following mild biliary pancreatitis.

Methods

Between 2004 and 2007, patients with acute pancreatitis were registered prospectively in 15 Dutch hospitals. Patients with mild biliary pancreatitis were candidates for cholecystectomy. Recurrent biliary events requiring admission before and after cholecystectomy, and after endoscopic sphincterotomy (ES), were evaluated.

Results

Of 308 patients with mild biliary pancreatitis, 267 were candidates for cholecystectomy. Eighteen patients underwent cholecystectomy during the initial admission, leaving 249 potential candidates for cholecystectomy after discharge. Cholecystectomy was performed after a median of 6 weeks in 188 patients (75·5 per cent). Before cholecystectomy, 34 patients (13·7 per cent) were readmitted for biliary events, including 24 with recurrent biliary pancreatitis. ES was performed in 108 patients during the initial admission. Eight (7·4 per cent) of these patients suffered from biliary events after ES and before cholecystectomy, compared with 26 (18·4 per cent) of 141 patients who did not have ES (risk ratio 0·51, 95 per cent confidence interval 0·27 to 0·94; P = 0·015). Following cholecystectomy, eight (3·9 per cent) of 206 patients developed biliary events after a median of 31 weeks. Only 142 (53·2 per cent) of 267 patients were treated in accordance with the Dutch guideline, which recommends cholecystectomy or ES during the index admission or within 3 weeks thereafter.

Conclusion

A delay in cholecystectomy after mild biliary pancreatitis carries a substantial risk of recurrent biliary events. ES reduces the risk of recurrent pancreatitis but not of other biliary events.

Cholecystectomy for Acute Gallstone Pancreatitis: Early Vs Delayed Approach

Background and Aims:

The management of gallstone pancreatitis, in particular timing of cholecystectomy, has evolved substantially over the last decade. The trend has been toward earlier cholecystectomy. We review current literature regarding the timing of cholecystectomy in the context of gallstone pancreatitis.

Materials and Methods:

The authors performed a literature search in PubMed for relevant articles in the English language with greatest weight given to prospective trials compared to observational studies and previous reviews.

Results:

The literature search yielded 59 articles discussing cholecystectomy in the context of gallstone pancreatitis. Most were retrospective studies or reviews, but there were nine prospective observational studies and two randomized control trials. For mild gallstone pancreatitis, laparoscopic cholecystectomy within 48 hours of presentation (without normalization of pancreatic enzymes or absence of abdominal pain) has been shown to shorten hospital stay without increased morbidity or mortality. Routine preoperative ERCP is unnecessary for patients with mild disease. For more severe disease, timing of cholecystectomy is governed by clinical status. Interval cholecystectomy (>2 weeks after index admission) can be safely done with low risk of recurrence if the patient has had ERCP and sphincterotomy at index admission.

Conclusion:

Patients with mild gallstone pancreatitis should have cholecystectomy during index admission within 48 hours of arrival, but patients with more severe disease will require cholecystectomy at a later time, depending on the clinical circumstances. Sphincterotomy should be done as soon as possible if cholecystectomy is not feasible early in course.

First attack of acute pancreatitis in Sweden 1988 - 2003: incidence, aetiological classification, procedures and mortality - a register study

Background

Population-based studies suggest that the incidence of first attack of acute pancreatitis (FAAP) is increasing and that old age is associated with increased mortality. Beacuse nationwide data are limited and information on standardized mortality ratio (SMR) versus age is lacking, we wanted to describe incidence and mortality of first attack acute pancreatitis (FAAP) in Sweden.

Methods

Hospital discharge data concerning diagnoses and surgical procedures and death certificate data were linked for patients with FAAP in Sweden. Mortality was calculated as case fatality rate (CFR), i.e. deaths per 1000 patients and SMR using age-, gender- and calendar year-specific expected survival estimates, and is given as mean with 95% confidence intervals. Data are presented as median values with 25% and 75% percentiles, means and standard deviations, or proportions. Proportions have been compared using the chi square test, Poisson-regression test or Fisher exact test. Location of two groups of ratio scale variables were compared using independent samples t-test or Mann-Whitney U-test.

Results

From 1988 through 2003, 43415 patients (23801 men and 19614 women) were admitted for FAAP. Age adjusted incidence rose from 27.0 to 32.0 per 100000 individuals and year. Incidence increased with age for both men and women. At index stay 19.7% of men and 35.4% of women had biliary diagnoses, and 7.1% of men and 2.1% of women alcohol-related diagnoses. Of 10072 patients who underwent cholecystectomy, 7521 (74.7%) did so after index stay within the audit period. With increasing age CFR increased and SMR decreased. For the whole period studied SMR was 11.75 (11.34–12.17) within 90 days of index admission and 2.03 (1.93–2.13) from 91 to 365 days. Alcohol-related diagnoses and young age was associated with increased SMR. Length of stay and SMR decreased significantly during the audit period.

Conclusion

Incidence of FAAP increased slightly from 1988 to 2003. Incidence increased and SMR declined with increasing patient age. Although the prognosis for patients with FAAP has improved it remains an important health problem. Aetiological classification at index stay and timing of cholecystectomy should be improved.