Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections

Abstract

Summary background data: Standard management of gallstone-associated acute pancreatitis calls for cholecystectomy to be performed during the same hospitalization after acute symptoms have subsided. However, infectious complications are common when cholecystectomy is performed sooner than 3 weeks after severe acute pancreatitis. Fluid collections, common in patients with moderate to severe acute pancreatitis, are additionally problematic. No previous study has examined the role of peripancreatic fluid collections and subsequent pseudocyst in outcomes after cholecystectomy in these patients.

Objectives: We compare results of delaying cholecystectomy after moderate to severe acute pancreatitis with early cholecystectomy.

Methods: Since 1987, all patients with moderate to severe gallstone-associated acute pancreatitis and associated fluid collections were addressed. Moderate to severe acute pancreatitis was defined as > 5 Ranson prognostic indicators. Fluid collection was established by computed tomography (CT) scan. Patients were evaluated for duration of hospitalization, complications of cholecystectomy, resolution or persistence of pseudocysts, nonoperative interventions performed on pseudocysts, intercurrent episodes of acute pancreatitis during the monitoring period, episodes of sepsis, and mortality.

Results: A total of 187 patients with moderate to severe gallstone-associated acute pancreatitis survived their acute stage; 151 had peripancreatic fluid collections. Seventy-eight of the 187 had early cholecystectomy, 62 of whom had fluid collections; 109 were monitored before cholecystectomy, 89 of whom had fluid collections. Fluid collections resolved without intervention in 36 (40%) of 89 in the monitored group and in 13 (21%) of 62 in the early cholecystectomy group. Percutaneous drainage was performed in 16 (18%) of 89 in the monitored group and in 31 (50%) of 62 in the early cholecystectomy group. Sepsis occurred in 6 (7%) of 89 in the monitored group and 29 (47%) of 62 in the early cholecystectomy group. Complications of cholecystectomy occurred in 6 (5.5%) of 109 of the monitored patients and in 34 (44%) of 78 in the early cholecystectomy group. Fifty-three patients in the monitored group and 49 patients in the early cholecystectomy group required operative pseudocyst-enterostomy. This procedure was combined with cholecystectomy in the monitored patients. Mean hospitalization was longer in the early operation group.

Conclusion: Cholecystectomy should be delayed in patients who survive an episode of moderate to severe acute biliary pancreatitis and demonstrate peripancreatic fluid collections or pseudocysts until the pseudocysts either resolve or persist beyond 6 weeks, at which time pseudocyst drainage can safely be combined with cholecystectomy.

Figures

FIGURE 1. Schematic representation of the categories of ductal abnormalities seen in patients with pseudocysts. Type I is a normal duct/no communication with cyst. Type II is normal duct with no duct/cyst communication. Type III is an otherwise normal duct with stricture and no duct/cyst communication. Type IV is an otherwise normal duct with stricture and communication between the duct and the cyst. Type V is an otherwise normal duct with a complete cut-off. Type VI is chronic pancreatitis, no communication between duct and cyst. Type VII is chronic pancreatitis with communication between duct and cyst.