Abstract
Introduction
Current guidelines recommend cholecystectomy (CCY) during the index admission for mild to moderate biliary pancreatitis as delayed CCY is associated with a substantial risk of recurrent biliary events. Delayed CCY is recommended in severe pancreatitis. The optimal timing of CCY in necrotizing pancreatitis, however, has not been well studied. We sought to determine the safety of single-stage CCY performed at the time of necrosectomy and its effectiveness in preventing subsequent biliary complications.
Methods
We retrospectively queried our institutional database of patients who underwent pancreatic necrosectomy for necrotizing pancreatitis from 1992 to 2012.
Results
We identified 217 consecutive patients who underwent pancreatic necrosectomy during the study period. The most common etiologies of pancreatitis were biliary (41 %) and alcoholic (24 %), with a median computed tomography (CT) severity index score of 6 ± 1.6 and a 63.6 % incidence of infected necrosis. Ninety-eight patients had undergone CCY prior to necrosectomy. Seventy patients (59 % of those with gallbladders in situ) underwent CCY at the time of pancreatic necrosectomy. CCY was not performed in the remaining 49 due to a clear non-biliary etiology (35 %), technical difficulty (29 %), intraoperative hemodynamic instability (18 %), or surgeon preference (18 %). Postoperative morbidity and mortality was no different between the CCY and no CCY groups, with no bile duct injury or bile leaks in patients undergoing CCY at the time of necrosectomy. Of the patients undergoing CCY, 43 % of patients without cholelithiasis or biliary sludge on preoperative imaging had gallstones or sludge identified pathologically after single-stage CCY. Of those who did not receive a single-stage CCY, biliary complications developed in 17 (35 %) of patients (21 % cholecystitis, 14 % recurrent gallstone pancreatitis) at a median time to incidence of 10 months. Seventeen (35 %) patients eventually received a postnecrosectomy cholecystectomy, of which 75 % required an open procedure.
Conclusion
Single-stage CCY at the time of pancreatic necrosectomy is safe in selected patients and should be performed if technically feasible to prevent future biliary complications and reduce the need for a subsequent separate, often open, CCY.
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Dr. Nicholas J Zyromski (Indianapolis, IN):
The authors demonstrate that cholecystectomy can safely be included at the same time as pancreatic necrosectomy in select patients. This highlights the excellent clinical judgement from this experienced group.
Two points are important. First, 35 % of patients who did not have cholecystectomy developed recurrent biliary symptoms (cholecystitis and pancreatitis) within the next 10 months. Secondly, 43 % of patients with no preoperative imaging evidence of biliary pathology (stones or sludge) ultimately were found to have either gallstones or sludge at final pathologic analysis.
I have two questions:
1.Regarding safety of cholecystectomy, can you tell us more information about intraoperative variables in these two groups—i.e., EBL, OR time, etc.
2.Tell us about your strategy regarding cholangiography—is this routine practice at MGH?
Closing Discussant
Dr. Zhi Ven Fong (Boston, MA)
Thank you, Dr. Zyromski, for your insightful comments. Your group has contributed to a great deal of our understanding of the disease process, and we are privileged to have a pancreatitis expert such as yourself to discuss our paper.
We decided to exclude the intraoperative variables in these two groups because metrics such as EBL, OR time, and need for blood transfusion are not likely to be representative of the feasibility of the cholecystectomy. Rather, it would be more of a reflection of the degree of necrosis and friability of the pancreatic parenchyma involved in the necrotizing process, which was very heterogeneous in both groups. Instead, we utilized end points like common bile duct injury and biliary leaks as end points that would be more reflective of the safety of single-stage CCY at the time of necrosectomy. That said, when the initial analysis was performed, there were no differences in EBL and OR time between both CCY and no CCY groups.
In addressing your second question, it depends on what we are performing the cholangiography for—to interrogate the biliary tract for gallstones or to delineate intraoperative biliary anatomy (cystic and common bile duct location) in technically difficult situations. There were very few cholangiograms performed in these patients. At MGH, we perform cholangiography for most patients needing a CCY after biliary pancreatitis, but not for run-of-the-mill cholecystitis or during CCY after non-biliary pancreatitis unless clinically indicated. In this series of CCYs done at the time of pancreatic debridement, if there was any belief that we needed a cholangiogram to ascertain intraoperative biliary anatomy, we would forego the CCY altogether (and the case would be categorized as no CCY because of technical difficulty as described in this manuscript).
That said, if a cholangiogram was done and common bile duct gallstones were found in the setting of a feasible CCY, we would hesitate to recommend a common bile duct exploration at the time of pancreatic debridement, but would favor a postoperative endoscopic sphincterotomy for most cases.
We would like to emphasize again that we are not advocating for single-stage CCY in all patients undergoing necrosectomy. Rather, our data suggest that if it is deemed technically feasible, and the patient is hemodynamically optimized to tolerate the additional procedure, a single-stage CCY should be performed to reduce the significant risk of subsequent biliary complication, which oftentimes necessitates a separate, open abdominal procedure.
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Fong, Z.V., Peev, M., Warshaw, A.L. et al. Single-Stage Cholecystectomy at the Time of Pancreatic Necrosectomy Is Safe and Prevents Future Biliary Complications: a 20-Year Single Institutional Experience with 217 Consecutive Patients. J Gastrointest Surg 19, 32–38 (2015). https://doi.org/10.1007/s11605-014-2650-x
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DOI: https://doi.org/10.1007/s11605-014-2650-x