title: Endoscopic sphincterotomy and interval cholecystectomy are reasonable alternatives to index cholecystectomy in severe acute gallstone pancreatitis (GSP).
abstract: BACKGROUND
  UK guidelines for gallstone pancreatitis (GSP) advocate definitive treatment during the index admission, or within 2 weeks of discharge. However, this target may not always be achievable. This study reviewed current management of GSP in a university hospital and evaluated the risk associated with interval cholecystectomy.
  
  
  METHODS
  All patients that presented with GSP over a 4-year period (2002-2005) were stratified for disease severity (APACHE II). Patient demographics, time to definitive therapy [index cholecystectomy; endoscopic sphincterotomy (ES); Interval cholecystectomy], and readmission rates were analysed retrospectively.
  
  
  RESULTS
  100 patients admitted with GSP. Disease severity was mild in 54 patients and severe in 46 patients. Twenty-two patients unsuitable for surgery underwent ES as definitive treatment with no readmissions. Seventy-eight patients underwent cholecystectomy, of which 40 (58%) had an index cholecystectomy, and 38 (42%) an interval cholecystectomy. Only 10 patients with severe GSP had an index cholecystectomy, whilst 30 were readmitted for Interval cholecystectomy (p = 0.04). The median APACHE score was 4 [standard deviation (SD) 3.8] for index cholecystectomy and 8 (SD 2.6) for Interval cholecystectomy (p < 0.05). Median time (range) to surgery was 7.5 (2-30) days for index cholecystectomy and 63 (13-210) days for Interval cholecystectomy. Fifty percent (19/38) of patients with GSP had ES prior to discharge for interval cholecystectomy. Two (5%) patients were readmitted: with acute cholecystitis (n = 1) and acute pancreatitis (n = 1) , whilst awaiting interval cholecystectomy. No mortality was noted in the Index or Interval group.
  
  
  CONCLUSIONS
  This study demonstrates that overall 62% (22 endoscopic sphincterotomy and 40 index cholecystectomy) of patients with GSP have definitive therapy during the Index admission. However, surgery was deferred in the majority (n = 30) of patients with severe GSP, and 19/30 underwent ES prior to discharge. ES and interval cholecystectomy in severe GSP is associated with minimal morbidity and readmission rates, and is considered a reasonable alternative to an index cholecystectomy in patients with severe GSP.
authors: Ninewells Hospital and Medical School, Dundee, DD2 9SY, Scotland, UK. sanjay.pandanaboyana@nhs.net
authors: Pandanaboyana
authors: P
authors: Sanjay
authors: Sim
authors: S
authors: Yeeting
authors: Carole
authors: C
authors: Whigham
authors: Hannah
authors: H
authors: Judson
authors: Francesco M
authors: FM
authors: Polignano
authors: Iain S
authors: IS
authors: Tait
mesh_terms: D000208:Acute Disease; D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D002763:Cholecystectomy / Q000009:adverse effects / Q000379:methods*; D005260:Female; D042882:Gallstones / Q000150:complications* / Q000601:surgery*; D006801:Humans; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D010195:Pancreatitis / Q000209:etiology* / Q000503:physiopathology; D010359:Patient Readmission / Q000706:statistics & numerical data; D012086:Reoperation; D012189:Retrospective Studies; D012720:Severity of Illness Index; D016717:Sphincterotomy, Endoscopic / Q000009:adverse effects; D013997:Time Factors