Early Versus Delayed Cholecystectomy Following Endoscopic Sphincterotomy for Mild Biliary Pancreatitis

Brett D Mador, BSc, MD, O Neely M Panton, MB, BS, FRCSC, FACS, S Morad Hameed, MD, MPH, FRCSC, FACS. University of British Columbia, Division of General Surgery.

INTRODUCTION: The recommended treatment for patients with mild acute biliary pancreatitis is early cholecystectomy performed during the index admission. However, the data is less clear in regards to patients who undergo endoscopic sphincterotomy prior to surgery. While it has been shown that these patients still benefit from cholecystectomy, the optimal timing of this intervention is not well defined. We hypothesized that delayed cholecystectomy following endoscopic sphincterotomy for mild biliary pancreatitis is associated with significant preventable morbidity.

METHODS AND PROCEDURES: A retrospective chart review was performed at two academic hospitals for patients diagnosed with biliary pancreatitis who underwent endoscopic sphincterotomy followed by cholecystectomy. Patients aged 18 and over admitted from 2006 – 2011 were included, while those with severe pancreatitis were excluded. The primary outcome was biliary complications experienced during the waiting period for cholecystectomy. Secondary outcomes included length of stay, operative complications and conversion rate. Student t-test was used to compare continuous data and Fischer’s exact test was used for categorical data.

RESULTS: 80 patient charts were reviewed. Time to cholecystectomy was 3.3 days (range 0.5-10) in the early group and 141.6 (range 18-757) in the delayed group. The groups were comparable in terms of age and American Society of Anesthesiologists (ASA) classification. 21 of 35 patients (60%) in the delayed group experienced biliary complications compared with 1 of 45 (2%) in the early group (p<0.001). 14 patients in the delayed group required re-admission (40%) and 5 (14%) required additional procedures. Secondary outcomes were not statistically significant.

CONCLUSIONS: The data demonstrate a significantly increased biliary complication rate associated with delayed cholecystectomy in this patient population. Early cholecystectomy should be strongly considered for patients with mild biliary pancreatitis even when endoscopic sphincterotomy has been performed pre-operatively.