Recurrence of idiopathic acute pancreatitis after cholecystectomy: systematic review and meta-analysis

D S Umans, N D Hallensleben, R C Verdonk, S A W Bouwense, P Fockens, H C van Santvoort, R P Voermans, M G Besselink, M J Bruno, J E van Hooft, Dutch Pancreatitis Study Group, D S Umans, N D Hallensleben, R C Verdonk, S A W Bouwense, P Fockens, H C van Santvoort, R P Voermans, M G Besselink, M J Bruno, J E van Hooft, Dutch Pancreatitis Study Group

Abstract

Background: Occult biliary disease has been suggested as a frequent underlying cause of idiopathic acute pancreatitis (IAP). Cholecystectomy has been proposed as a strategy to prevent recurrent IAP. The aim of this systematic review was to determine the efficacy of cholecystectomy in reducing the risk of recurrent IAP.

Methods: PubMed, Embase and Cochrane Library databases were searched systematically for studies including patients with IAP treated by cholecystectomy, with data on recurrence of pancreatitis. Studies published before 1980 or including chronic pancreatitis and case reports were excluded. The primary outcome was recurrence rate. Quality was assessed using the Newcastle-Ottawa Scale. Meta-analyses were undertaken to calculate risk ratios using a random-effects model with the inverse-variance method.

Results: Overall, ten studies were included, of which nine were used in pooled analyses. The study population consisted of 524 patients with 126 cholecystectomies. Of these 524 patients, 154 (29·4 (95 per cent c.i. 25·5 to 33·3) per cent) had recurrent disease. The recurrence rate was significantly lower after cholecystectomy than after conservative management (14 of 126 (11·1 per cent) versus 140 of 398 (35·2 per cent); risk ratio 0·44, 95 per cent c.i. 0·27 to 0·71). Even in patients in whom IAP was diagnosed after more extensive diagnostic testing, including endoscopic ultrasonography or magnetic resonance cholangiopancreatography, the recurrence rate appeared to be lower after cholecystectomy (4 of 36 (11 per cent) versus 42 of 108 (38·9 per cent); risk ratio 0·41, 0·16 to 1·07).

Conclusion: Cholecystectomy after an episode of IAP reduces the risk of recurrent pancreatitis. This implies that current diagnostics are insufficient to exclude a biliary cause.

© 2019 The Authors. BJS published by John Wiley & Sons Ltd on behalf of BJS Society Ltd.

Figures

Figure 1
Figure 1
Diagnostic process and definitions IAP, idiopathic acute pancreatitis; ERCP, endoscopic retrograde cholangiopancreatography; EUS endoscopic ultrasonography; MRCP, magnetic resonance cholangiopancreatography.
Figure 2
Figure 2
PRISMA flow chart showing selection of articles for review
Figure 3
Figure 3
Pooled analysis of recurrence of pancreatitis in patients with ‘presumed’ idiopathic acute pancreatitis treated with cholecystectomy versus conservative management Risk ratios are shown with 95 per cent confidence intervals. A random‐effects inverse‐variance model was used for meta‐analysis.
Figure 4
Figure 4
Pooled analysis of recurrence of pancreatitis in patients with ‘true’ idiopathic acute pancreatitis treated with cholecystectomy versus conservative management Risk ratios are shown with 95 per cent confidence intervals. A random‐effects inverse‐variance model was used for meta‐analysis.

References

    1. Roberts SE, Morrison‐Rees S, John A, Williams JG, Brown TH, Samuel DG. The incidence and aetiology of acute pancreatitis across Europe. Pancreatology 2017; 17: 155–165.
    1. Nesvaderani M, Eslick GD, Vagg D, Faraj S, Cox MR. Epidemiology, aetiology and outcomes of acute pancreatitis: a retrospective cohort study. Int J Surg 2015; 23: 68–74.
    1. Chen Y, Zak Y, Hernandez‐Boussard T, Park W, Visser BC. The epidemiology of idiopathic acute pancreatitis, analysis of the nationwide inpatient sample from 1998 to 2007. Pancreas 2013; 42: 1–5.
    1. Lee SP, Nicholls JF, Park HZ. Biliary sludge as a cause of acute pancreatitis. N Engl J Med 1992; 326: 589–593.
    1. Garg PK, Tandon RK, Madan K. Is biliary microlithiasis a significant cause of idiopathic recurrent acute pancreatitis? A long‐term follow‐up study. Clin Gastroenterol Hepatol 2007; 5: 75–79.
    1. Jüngst C, Kullak‐Ublick GA, Jüngst D. Gallstone disease: microlithiasis and sludge. Best Pract Res Clin Gastroenterol 2006; 20: 1053–1062.
    1. da Costa DW, Bouwense SA, Schepers NJ, Besselink MG, van Santvoort HC, van Brunschot S et al; Dutch Pancreatitis Study Group . Same‐admission versus interval cholecystectomy for mild gallstone pancreatitis (PONCHO): a multicentre randomised controlled trial. Lancet 2015; 386: 1261–1268.
    1. Räty S, Pulkkinen J, Nordback I, Sand J, Victorzon M, Grönroos J et al Can laparoscopic cholecystectomy prevent recurrent idiopathic acute pancreatitis?: A prospective randomized multicenter trial. Ann Surg 2015; 262: 736–741.
    1. Stevens CL, Abbas SM, Watters DA. How does cholecystectomy influence recurrence of idiopathic acute pancreatitis? J Gastrointest Surg 2016; 20: 1997–2001.
    1. Wan J, Ouyang Y, Yu C, Yang X, Xia L, Lu N. Comparison of EUS with MRCP in idiopathic acute pancreatitis: a systematic review and meta‐analysis. Gastrointest Endosc 2018; 87: 1180–1188.e9.
    1. Moher D, Liberati A, Tetzlaff J, Altman DG; The PRISMA Group . Preferred reporting items for systematic reviews and meta‐analyses: the PRISMA statement. PLoS Med 2009; 6: e1000097.
    1. Stroup DF, Berlin JA, Morton SC, Olkin I, Williamson GD, Rennie D et al Meta‐analysis of observational studies in epidemiology: a proposal for reporting. Meta‐analysis Of Observational Studies in Epidemiology (MOOSE) group. JAMA 2000; 283: 2008–2012.
    1. Working Group IAP/APA Acute Pancreatitis Guidelines . IAP/APA evidence‐based guidelines for the management of acute pancreatitis. Pancreatology. 2013; 13(Suppl 2): e1–e15.
    1. Banks PA, Bollen TL, Dervenis C, Gooszen HG, Johnson CD, Sarr MG et al; Acute Pancreatitis Classification Working Group . Classification of acute pancreatitis – 2012: revision of the Atlanta classification and definitions by international consensus. Gut 2013; 62: 102–111.
    1. Wells GA, Shea B, O'Connell D, Peterson J, Welch V, Losos M et al The Newcastle‐Ottawa Scale (NOS) for assessing the quality if nonrandomized studies in meta‐analyses; 2012. [accessed 9 August 2018].
    1. Higgins JP, Thompson SG, Deeks JJ, Altman DG. Measuring inconsistency in meta‐analyses. BMJ 2003; 327: 557–560.
    1. Sterne JA, Egger M. Funnel plots for detecting bias in meta‐analysis: guidelines on choice of axis. J Clin Epidemiol 2001; 54: 1046–1055.
    1. Sterne JA, Gavaghan D, Egger M. Publication and related bias in meta‐analysis: power of statistical tests and prevalence in the literature. J Clin Epidemiol 2000; 53: 1119–1129.
    1. Trna J, Vege SS, Pribramska V, Chari ST, Kamath PS, Kendrick ML et al Lack of significant liver enzyme elevation and gallstones and/or sludge on ultrasound on day 1 of acute pancreatitis is associated with recurrence after cholecystectomy: a population‐based study. Surgery 2012; 151: 199–205.
    1. Pérez‐Martín G, Gómez‐Cerezo J, Codoceo R, Olveira A, Conde P, Garcés MC et al Bilirubinate granules: main pathologic bile component in patients with idiopathic acute pancreatitis. Am J Gastroenterol 1998; 93: 360–362.
    1. Saraswat VA, Sharma BC, Agarwal DK, Kumar R, Negi TS, Tandon RK. Biliary microlithiasis in patients with idiopathic acute pancreatitis and unexplained biliary pain: response to therapy. J Gastroenterol Hepatol 2004; 19: 1206–1211.
    1. Liu CL, Lo C‐M, Chan JKF, Poon RTP, Fan S‐T. EUS for detection of occult cholelithiasis in patients with idiopathic pancreatitis. Gastrointest Endosc 2000; 51: 28–32.
    1. Ortega AR, Gómez‐Rodríguez R, Romero M, Fernández‐Zapardiel S, Céspedes Mdel M, Carrobles JM. Prospective comparison of endoscopic ultrasonography and magnetic resonance cholangiopancreatography in the etiological diagnosis of ‘idiopathic’ acute pancreatitis. Pancreas 2011; 40: 289–294.
    1. Tandon M, Topazian M. Endoscopic ultrasound in idiopathic acute pancreatitis. Am J Gastroenterol 2001; 96: 705–709.
    1. DiMagno MJ, Wamsteker EJ. Pancreas divisum. Curr Gastroenterol Rep 2011; 13: 150–156.
    1. Ahmed Ali U, Issa Y, Hagenaars JC, Bakker OJ, van Goor H, Nieuwenhuijs VB et al Risk of recurrent pancreatitis and progression to chronic pancreatitis after a first episode of acute pancreatitis. Clin Gastroenterol Hepatol 2016; 14: 738–746.
    1. Wilcox CM, Seay T, Kim H, Varadarajulu S. Prospective endoscopic ultrasound‐based approach to the evaluation of idiopathic pancreatitis: causes, response to therapy, and long‐term outcome. Am J Gastroenterol 2016; 111: 1339–1348.

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