Delays in gallstone pancreatitis surgery increase risks

The recommended treatment for mild gallstone pancreatitis in patients aged over 50 years is laparoscopic cholecystectomy, yet over half of New South Wales patients presenting with the condition did not undergo the surgery at first presentation (index), risking conversion to open surgery and emergency readmissions.

Research, published today in the Medical Journal of Australia, analyzed linked hospitalization and death data for all people aged 50 years or more with mild gallstone pancreatitis who underwent cholecystectomy in New South Wales within 12 months of their index admission, 1 July 2008 to 30 June 2018.

"Larger proportions of people who underwent interval [rather than index] cholecystectomy were re-admitted within 28 days (246, 8.2% v 23, 1.3%) or 180 days (527, 17.6% v 59, 3.2%), or required open cholecystectomy (238, 7.9% v 69, 3.8%)," reported the authors, led by Dr. Jian Blundell, from Prince of Wales Hospital and Community Health Services in Sydney.

"Mean [hospital] length of stay was longer for index than interval cholecystectomy (7.7 days v 5.3 days) but 6-month total length of stay was similar (8.2 days v 7.9 days).

"For people with mild gallstone pancreatitis—that is, without organ failure or local or systemic complications—international guidelines recommend that laparoscopic cholecystectomy be performed during the index admission," Blundell and colleagues wrote.

"Delaying cholecystectomy increases the risks of recurrent gallstone-related disease within 30 days of discharge, including those of pancreatitis, cholecystitis, and cholangitis. Re-admission with gallstone-related disease after delayed cholecystectomy also increases the costs of treatment.

"Two-year re-admission rates as high as 44% have been reported in older people aged 65 years or more."

Blundell and colleagues wrote that delaying surgery could result in "chronic inflammation and subsequent complicated biliary disease and intra-abdominal adhesions" which may make the laparoscopic approach more difficult.

"The risk of open cholecystectomy is particularly relevant in older people, for whom recovery from an open procedure is more challenging, given the increased risk of post-operative complications and the longer recovery time."

The authors identified several factors that may influence the likelihood of delayed surgery.

"The association between low and medium surgical volume and interval cholecystectomy probably reflects lower surgeon availability and lack of access to dedicated emergency surgery operating time in public hospitals, particularly in lower volume centers … our findings possibly indicate systemic problems with the delivery of regional emergency general surgery," they wrote.

"Despite the generally higher risk associated with surgery in people aged 50 years or more, cholecystectomy for mild gallstone pancreatitis should be performed, when possible, during the index admission," Blundell and colleagues concluded.

"Accordingly, patient-, service-, and surgeon-related factors implicated in delaying cholecystectomy should be further investigated, ideally using a standardized quality improvement approach."