Early Gallstone Surgery Has No Downside

The common practice of delaying laparoscopic cholecystectomy (LC) in patients with gallstone pancreatitis until laboratory values stabilize lengthens hospital stay without benefit to patients, according to a new study.

Researchers at the Olive View-UCLA Medical Center (Sylmar, CA, USA) conducted a retrospective review involving 303 patients with mild gallstone pancreatitis, of whom 117 underwent an early LC and 186 underwent a delayed LC. For those who had surgery more than 48 hours after admission, the most common reason for the delay was waiting for normalization of bilirubin or pancreatic enzyme levels, secondary to surgeon preference. The main outcome measures were hospital length of stay, morbidity and mortality rates, and the use of endoscopic retrograde cholangiopancreatography (ERCP).

The results showed that similar hospital admission variables were observed in the early and delayed LC groups, although the delayed group was older. The median hospital length of stay was significantly less for the early group (three days) than for the delayed group (six days). There were no patients who died, and the complication rates were similar for both groups. However, the patients who underwent an early LC were less likely than patients who underwent a delayed LC to undergo ERCP (16% versus 27%, respectively), usually performed for persistent elevation of the total bilirubin level or a dilated common bile duct. The study was published early online on July 16, 2012, in Archives of Surgery.

“We believe that the safety of an early laparoscopic cholecystectomy lies in the identification and exclusion of patients who may be at risk of progressing to a more severe pancreatitis, such as those with tachycardia, elevated serum urea nitrogen level, or evidence of cholangitis at hospital admission,” concluded lead author Darin Saltzman, MD, PhD, and colleagues of the departments of medicine and emergency medicine. “The practice of delaying a laparoscopic cholecystectomy until normalization of laboratory values appears to be unnecessary; it's time for a paradigm shift.”

Acute biliary pancreatitis is a common clinical scenario encountered by the general surgeon. The etiology can be explained by the “common channel” theory, in which the ampulla of Vater is transiently obstructed by a gallstone, leading to pancreatic inflammation and autodigestion. Since most of the offending stones are passed into the feces, the ensuing pancreatitis is generally mild and can often be managed supportively. To prevent further episodes, elective LC is routinely performed during the same hospital admission to remove the source of calculi.

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Olive View-UCLA Medical Center