Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis
Marcello Di Martino, Benedetto Ielpo, Francesco Pata, Gianluca Pellino, Salomone Di Saverio, Fausto Catena, Belinda De Simone, Federico Coccolini, Massimo Sartelli, Dimitrios Damaskos, Damian J. Mole, Valentina Murzi, Ari Leppäniemi, Adolfo Pisanu, Mauro Podda, MANCTRA-1 Collaborative Group, Chiara Gerardi, Francesco Virdis, Daniela Pacella, Kumar Jayant, Ferdinando Agresta, Cristiana Riboni, Yoram Kluger, Martín de Santibañes, Juliana Di Menno Stavron, Oscar Mazza, José Ignacio Valenzuela, Diana AP Pachajoa, Fernando A. Alvarez, Julián E. Liaño, Justin S. Gundara, Joan Tefay, Kamel Alawadhi, Abdulrahman Alshaikh, Layla Hasan, Carlos Augusto Gomes, Felipe Couto GOMES, Gustavo Pereira Fraga, Thiago RA Calderan, Elcio S Hirano, Dragomir Dardanov, Alexander Julianov, Azize Saroglu, Boyko Atanasov, Nikolay Belev, Nikola Kovachev, Rashid N. Lui, Shannon M. Chan, Hon‐Ting Lok, Diego Salcedo, Diana Robayo, María Alejandra Triviño, Jan Maňák, Saaz Sahani, Jorann de Araujo, Ananya Sethi, Ahmed Awad, Merihan A. Elbadawy, Ahmed M. Farid, Asmaa Hanafy, Ahmed Nafea, Sherief Ghozy, Alzhraa Salah–Abbas, Wafaa Abdelsalam, Sameh Hany Emile, Ahmed Hossam Elfallal, Hossam Elfeki, Hosam Elghadban, Ashraf Shoma, Mohamed Shetiwy, Mohamed Elbahnasawy, Salem Youssef Mohamed, Emad Hamed, Osama A. Khalil, Élie Chouillard, Andrew A. Gumbs, Andréa Police, Andrea Mabilia, Zaza Demetrashvili, Kakhi Khutsishvili, Anano Tvaladze, Orestis Ioannidis, Εlissavet Anestiadou, Lydia Loutzidou, Argyrios Ioannidis, Konstantinis Konstantinidis, Sofia Konstantinidou, Dimitrios K. Manatakis, Vasileios Acheimastos, Nikolaos Tasis, Nikolaos V. Michalopoulos, Panagiotis Kokoropoulos, Maria Papadoliopoulou, Maria Sotiropoulou, Stylianos Kapiris, Panagiotis Metaxas, Ioannis Tsouknidas, Despoina Kefili, George Petrakis, Eirini Synekidou
Abstract
Importance: Considering the lack of equipoise regarding the timing of cholecystectomy in patients with moderately severe and severe acute biliary pancreatitis (ABP), it is critical to assess this issue. Objective: To assess the outcomes of early cholecystectomy (EC) in patients with moderately severe and severe ABP. Design, Settings, and Participants: This cohort study retrospectively analyzed real-life data from the MANCTRA-1 (Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis) data set, assessing 5304 consecutive patients hospitalized between January 1, 2019, and December 31, 2020, for ABP from 42 countries. A total of 3696 patients who were hospitalized for ABP and underwent cholecystectomy were included in the analysis; of these, 1202 underwent EC, defined as a cholecystectomy performed within 14 days of admission. Univariable and multivariable logistic regression models were used to identify prognostic factors of mortality and morbidity. Data analysis was performed from January to February 2023. Main Outcomes: Mortality and morbidity after EC. Results: Of the 3696 patients (mean [SD] age, 58.5 [17.8] years; 1907 [51.5%] female) included in the analysis, 1202 (32.5%) underwent EC and 2494 (67.5%) underwent delayed cholecystectomy (DC). Overall, EC presented an increased risk of postoperative mortality (1.4% vs 0.1%, P < .001) and morbidity (7.7% vs 3.7%, P < .001) compared with DC. On the multivariable analysis, moderately severe and severe ABP were associated with increased mortality (odds ratio [OR], 361.46; 95% CI, 2.28-57 212.31; P = .02) and morbidity (OR, 2.64; 95% CI, 1.35-5.19; P = .005). In patients with moderately severe and severe ABP (n = 108), EC was associated with an increased risk of mortality (16 [15.6%] vs 0 [0%], P < .001), morbidity (30 [30.3%] vs 57 [5.5%], P < .001), bile leakage (2 [2.4%] vs 4 [0.4%], P = .02), and infections (12 [14.6%] vs 4 [0.4%], P < .001) compared with patients with mild ABP who underwent EC. In patients with moderately severe and severe ABP (n = 108), EC was associated with higher mortality (16 [15.6%] vs 2 [1.2%], P < .001), morbidity (30 [30.3%] vs 17 [10.3%], P < .001), and infections (12 [14.6%] vs 2 [1.3%], P < .001) compared with patients with moderately severe and severe ABP who underwent DC. On the multivariable analysis, the patient's age (OR, 1.12; 95% CI, 1.02-1.36; P = .03) and American Society of Anesthesiologists score (OR, 5.91; 95% CI, 1.06-32.78; P = .04) were associated with mortality; severe complications of ABP were associated with increased mortality (OR, 50.04; 95% CI, 2.37-1058.01; P = .01) and morbidity (OR, 33.64; 95% CI, 3.19-354.73; P = .003). Conclusions and Relevance: This cohort study's findings suggest that EC should be considered carefully in patients with moderately severe and severe ABP, as it was associated with increased postoperative mortality and morbidity. However, older and more fragile patients manifesting severe complications related to ABP should most likely not be considered for EC.