title: Gallstone pancreatitis in older patients: Are we operating enough?
abstract: BACKGROUND
  The recommended therapy for mild gallstone pancreatitis is cholecystectomy on initial hospitalization.
  
  
  METHODS
  Using a 5% national Medicare sample (1996-2005), we evaluated adherence to current recommendations for gallstone pancreatitis (cholecystectomy rates on initial hospitalization and the use of endoscopic retrograde cholangiopancreatography [ERCP]/sphincterotomy). We evaluated predictors of cholecystectomy, gallstone-related readmissions, and 2-year mortality.
  
  
  RESULTS
  Adherence to current guidelines was low. Only 57% of 8,452 Medicare beneficiaries presenting to an acute care hospital with a first episode of mild gallstone pancreatitis underwent cholecystectomy on initial hospitalization. Of the patients who did not undergo cholecystectomy, 55% were never evaluated by a surgeon. Likewise, only 28% of patients who did not undergo cholecystectomy had a sphincterotomy. The 2-year readmission rates were higher among patients who did not undergo cholecystectomy (44% vs 4%; P < .0001), and 33% of these patients required cholecystectomy after discharge. In the no cholecystectomy group, ERCP prevented readmissions (hazard ratio, 0.53; 95% confidence interval, 0.47-0.61) and when readmissions occurred they were less likely to be for gallstone pancreatitis in patients who had an ERCP (27.8% vs 53.2%; P < .0001). On multivariate analysis, patients who were older, black, admitted to a nonsurgical service, lived in certain US regions, and had specific comorbidities were less likely to undergo cholecystectomy.
  
  
  CONCLUSIONS
  Adherence to current recommendations for the management of mild gallstone pancreatitis is low in older patients. Our data suggest that >40% of patients who did not undergo cholecystectomy would have benefited from early definitive therapy. Implementation of policies to increase adherence to guidelines would prevent gallstone-related morbidity and mortality in older patients.
authors: Department of Surgery, The University of Texas Medical Branch, Galveston, TX, USA.
authors: Marc D
authors: MD
authors: Trust
authors: Kristin M
authors: KM
authors: Sheffield
authors: Casey A
authors: CA
authors: Boyd
authors: Jaime
authors: J
authors: Benarroch-Gampel
authors: Dong
authors: D
authors: Zhang
authors: Courtney M
authors: CM
authors: Townsend
authors: Taylor S
authors: TS
authors: Riall
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002760:Cholangiopancreatography, Endoscopic Retrograde / Q000379:methods; D017081:Cholecystectomy, Laparoscopic / Q000379:methods / Q000706:statistics & numerical data*; D015331:Cohort Studies; D016208:Databases, Factual; D005260:Female; D005500:Follow-Up Studies; D042882:Gallstones / Q000150:complications / Q000000981:diagnostic imaging / Q000401:mortality / Q000601:surgery*; D015577:Geriatric Assessment; D019983:Guideline Adherence; D006801:Humans; D053208:Kaplan-Meier Estimate; D008297:Male; D006278:Medicare / Q000706:statistics & numerical data; D015999:Multivariate Analysis; D017063:Outcome Assessment, Health Care; D010195:Pancreatitis / Q000000981:diagnostic imaging / Q000209:etiology / Q000401:mortality / Q000601:surgery*; D010359:Patient Readmission / Q000706:statistics & numerical data; D011183:Postoperative Complications / Q000453:epidemiology / Q000503:physiopathology; D017410:Practice Guidelines as Topic; D016016:Proportional Hazards Models; D012008:Recurrence; D012189:Retrospective Studies; D012307:Risk Factors; D016717:Sphincterotomy, Endoscopic; D015996:Survival Rate; D016896:Treatment Outcome; D014481:United States