Early cholecystectomy must be carefully considered in acute biliary pancreatitis

Older and more fragile patients who present with severe complications associated with acute biliary pancreatitis (ABP) may not be the best candidates for early cholecystectomy, real-life data from the MANCTRA-1* study.

MANCTRA-1 included 5,304 consecutive patients hospitalized for ABP. Of these, 3,696 (mean age 58.5 years, 51.5 percent women) underwent cholecystectomy and were included in the analysis. A total of 1,202 patients (32.5 percent) underwent early cholecystectomy (performed within 14 days of admission), while 2,494 (67.5 percent) had delayed cholecystectomy.

Compared with the delayed group, the early group had an elevated risk of postoperative mortality (1.4 percent vs 0.1 percent; p<0.001) and morbidity (7.7 percent vs 3.7 percent; p<0.001). Multivariable analysis showed that moderately severe and severe ABP were associated with greater odds of mortality (odds ratio [OR], 361.46, 95 percent confidence interval [CI], 2.28–57,212.31; p=0.02) and morbidity (OR, 2.64, 95 percent CI, 1.35–5.19; p=0.005).

Among patients with moderately severe and severe ABP (n=108), early cholecystectomy did more harm than good, being associated with an increased risk of mortality (15.6 percent vs 0 percent; p<0.001), morbidity (30.3 percent vs 5.5 percent; p<0.001), bile leakage (2.4 percent vs 0.4 percent; p=0.02), and infections (14.6 percent vs 0.4 percent; p<0.001) relative to patients with mild ABP.

Factors such as patient age (OR, 1.12, 95 percent CI, 1.02–1.36; p=0.03) and American Society of Anesthesiologists score (OR, 5.91, 95 percent CI, 1.06–32.78; p=0.04) were associated with increased mortality following early cholecystectomy. Meanwhile, severe complications of ABP were associated with higher mortality (OR, 50.04, 95 percent CI, 2.37–1,058.01; p=0.01) and morbidity (OR, 33.64, 95 percent CI, 3.19–354.73; p=0.003).

*Compliance With Evidence-Based Clinical Guidelines in the Management of Acute Biliary Pancreatitis