Gallstone Pancreatitis

Abstract

Hwang and colleagues1 offer an interesting look into the management of gallstone pancreatitis through the lens of an integrated health care system, Kaiser Permanente Southern California. The Kaiser system (compared with other insurance plans or hospitals) offers a unique opportunity to study this issue. They have a largely closed system offering synchronized care among various health care providers, and fewer patients move in and out of their umbrella of care. Thus, the article by Hwang et al is an important addition to the current literature suggesting that the recurrence of gallstone pancreatitis is all too common.2 Their data also suggest that endoscopic retrograde cholangiopancreatography (ERCP) during the index admission in patients who do not undergo cholecystectomy may be beneficial in preventing recurrent disease. In their cohort of 1119 patients who did not undergo cholecystectomy, 14.6% developed recurrent gallstone pancreatitis and 11.0% developed other issues related to gallstone disease. In patients who underwent ERCP, there was a 50% reduction in recurrent gallstone pancreatitis. Nonetheless, the risk of recurrence after ERCP remains elevated when compared with patients who underwent cholecystectomy (8.2% vs 5.4%, respectively). Accordingly, we agree with the authors that ERCP for the “definitive” management of gallstone pancreatitis3 should still be reserved for patients with a strong contraindication to surgery. This article also highlightswhatwe view as an even bigger problem: the significant proportion of patients (nearly 40% in thisstudy)whostilldonotundergocholecystectomyduringthe index hospitalization, including 20%who never go on to cholecystectomy. This problem is surely not unique to the Kaiser Permanente system,but rather ispervasive (andmaybeworse) throughout most hospitals. We fear that although some patientsdonotproceed to cholecystectomyowing to clinical factorsorpersonalpreference, in toomanycases theobstaclemay simply be convenience or the packed operating room schedule.Evenintervalcholecystectomyfollowingmildgallstonepancreatitis is associatedwith higher rates of recurrence and thus readmission.4 Inan increasinglycost-consciousandoutcomesdrivenhealth care environment, the importanceof thesemanagement decisions cannot be overlooked. Moreover, recent literature5has suggested thateven the inhospital “cooling-off”period isunnecessary.Patientswithmild gallstone pancreatitis can, in fact, safely undergo laparoscopic cholecystectomywithin24 to48hours regardlessof the resolution of abdominal pain or abnormal laboratory findings.Endoscopic retrogradecholangiopancreatographyshould infrequently enter the algorithm for the management of mild gallstone pancreatitis: in patientswith concomitant cholangitis, theuncommon retained stone, or extensive comorbidities precluding surgery. Evidence-based practice for the managementofmildgallstonepancreatitismust includeearly involvement of the surgeon leading to timely cholecystectomy.