Gallstone pancreatitis in older patients: Are we operating enough?

Abstract

Background: The recommended therapy for mild gallstone pancreatitis is cholecystectomy on initial hospitalization.

Methods: Using a 5% national Medicare sample (1996-2005), we evaluated adherence to current recommendations for gallstone pancreatitis (cholecystectomy rates on initial hospitalization and the use of endoscopic retrograde cholangiopancreatography [ERCP]/sphincterotomy). We evaluated predictors of cholecystectomy, gallstone-related readmissions, and 2-year mortality.

Results: Adherence to current guidelines was low. Only 57% of 8,452 Medicare beneficiaries presenting to an acute care hospital with a first episode of mild gallstone pancreatitis underwent cholecystectomy on initial hospitalization. Of the patients who did not undergo cholecystectomy, 55% were never evaluated by a surgeon. Likewise, only 28% of patients who did not undergo cholecystectomy had a sphincterotomy. The 2-year readmission rates were higher among patients who did not undergo cholecystectomy (44% vs 4%; P < .0001), and 33% of these patients required cholecystectomy after discharge. In the no cholecystectomy group, ERCP prevented readmissions (hazard ratio, 0.53; 95% confidence interval, 0.47-0.61) and when readmissions occurred they were less likely to be for gallstone pancreatitis in patients who had an ERCP (27.8% vs 53.2%; P < .0001). On multivariate analysis, patients who were older, black, admitted to a nonsurgical service, lived in certain US regions, and had specific comorbidities were less likely to undergo cholecystectomy.

Conclusion: Adherence to current recommendations for the management of mild gallstone pancreatitis is low in older patients. Our data suggest that >40% of patients who did not undergo cholecystectomy would have benefited from early definitive therapy. Implementation of policies to increase adherence to guidelines would prevent gallstone-related morbidity and mortality in older patients.

Figure 1

Time trends in the use of cholecystectomy during initial hospitalization. The U.K guidelines were introduced in 1998 and the IAP guidelines in 2002.

Figure 2

Subsequent gallstone-related healthcare trajectory in patients undergoing cholecystectomy during initial hospitalization for gallstone pancreatitis.

Figure 3

Subsequent gallstone-related healthcare trajectory in patients not undergoing cholecystectomy during initial hospitalization for gallstone pancreatitis.

Figure 4

Figure 4a. Kaplan-Meier readmission-free survival in patients who did and did not undergo cholecystectomy during initial hospitalization for gallstone pancreatitis. The 2-year readmission-free survival was 96.2% in the cholecystectomy group (3.8% 2-year readmission rate) and 56.5% in the no cholecystectomy group (43.5% 2-year readmission rate, p<0.0001). Figure 4b. Kaplan-Meier readmission-free in patients in the no cholecystectomy group who did and did not undergo ERCP during initial hospitalization for gallstone pancreatitis. The 2-year readmission-free survival was 68.9% in the ERCP group (31.1% 2-year readmission rate) compared to 51.5% in the no ERCP group (2-year readmission rate 48.5%, P<0.0001).