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Comment
. 2023 Oct 1;158(10):e233660.
doi: 10.1001/jamasurg.2023.3660. Epub 2023 Oct 11.

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

Marcello Di Martino  1 , Benedetto Ielpo  2 , Francesco Pata  3   4 , Gianluca Pellino  5   6 , Salomone Di Saverio  7 , Fausto Catena  8 , Belinda De Simone  9 , Federico Coccolini  10 , Massimo Sartelli  11 , Dimitrios Damaskos  12 , Damian Mole  13 , Valentina Murzi  14 , Ari Leppaniemi  15 , Adolfo Pisanu  14 , Mauro Podda  14 ; MANCTRA-1 Collaborative Group
Collaborators, Affiliations
Comment

Timing of Cholecystectomy After Moderate and Severe Acute Biliary Pancreatitis

Marcello Di Martino et al. JAMA Surg. .

Erratum in

  • Errors in Results and Table 2.
    [No authors listed] [No authors listed] JAMA Surg. 2024 Mar 1;159(3):353. doi: 10.1001/jamasurg.2023.7086. JAMA Surg. 2024. PMID: 38198149 Free PMC article. No abstract available.

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.

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Conflict of interest statement

Conflict of Interest Disclosures: Dr Mole reported serving as a director at APPreSci Ltd and Kynos Therapeutics Ltd outside the submitted work. No other disclosures were reported.

Figures

Figure 1.
Figure 1.. Study Flow Diagram
ABP indicates acute biliary pancreatitis; DC, delayed cholecystectomy; EC, early cholecystectomy; and MANCTRA-1, Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis.
Figure 2.
Figure 2.. Factors Associated With Postoperative Mortality and Morbidity in Patients With Acute Biliary Pancreatitis (ABP) Undergoing Early Cholecystectomy
The patients were classified as having mild, moderately severe, or severe ABP according to the revised Atlanta classification (RAC). Complications of ABP include abdominal compartment syndrome, bowel ischemia, and bowel fistula. Vertical line indicates the line of no effect. AOR indicates adjusted odds ratio; ASA, American Society of Anesthesiologists; and NA, not available.
Figure 3.
Figure 3.. Variables Associated With Postoperative Mortality and Morbidity in Patients With Moderately Severe and Severe Acute Biliary Pancreatitis (ABP) Undergoing Early Cholecystectomy
The patients were classified as having mild, moderately severe, or severe ABP according to the revised Atlanta classification (RAC). Complications of ABP include abdominal compartment syndrome, bowel ischemia, and bowel fistula. Vertical line indicates the line of no effect. AOR indicates adjusted odds ratio; ASA, American Society of Anesthesiologists; ERCP, endoscopic retrograde cholangiopancreatography; and NA, not available.
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