title: Single-stage cholecystectomy at the time of pancreatic necrosectomy is safe and prevents future biliary complications: a 20-year single institutional experience with 217 consecutive patients.
abstract: BACKGROUND
  Current guidelines recommend cholecystectomy (CCY) during the index admission for mild to moderate biliary pancreatitis as delayed CCY is associated with a substantial risk of recurrent biliary events. Delayed CCY is recommended in severe pancreatitis. The optimal timing of CCY in necrotizing pancreatitis, however, has not been well studied. We sought to determine the safety of single-stage CCY performed at the time of necrosectomy and its effectiveness in preventing subsequent biliary complications.
  
  
  METHODS
  We retrospectively queried our institutional database of patients who underwent pancreatic necrosectomy for necrotizing pancreatitis from 1992 to 2012.
  
  
  RESULTS
  We identified 217 consecutive patients who underwent pancreatic necrosectomy during the study period. The most common etiologies of pancreatitis were biliary (41 %) and alcoholic (24%), with a median computed tomography (CT) severity index score of 6 ± 1.6 and a 63.6% incidence of infected necrosis. Ninety-eight patients had undergone CCY prior to necrosectomy. Seventy patients (59% of those with gallbladders in situ) underwent CCY at the time of pancreatic necrosectomy. CCY was not performed in the remaining 49 due to a clear non-biliary etiology (35%), technical difficulty (29%), intraoperative hemodynamic instability (18%), or surgeon preference (18%). Postoperative morbidity and mortality was no different between the CCY and no CCY groups, with no bile duct injury or bile leaks in patients undergoing CCY at the time of necrosectomy. Of the patients undergoing CCY, 43% of patients without cholelithiasis or biliary sludge on preoperative imaging had gallstones or sludge identified pathologically after single-stage CCY. Of those who did not receive a single-stage CCY, biliary complications developed in 17 (35%) of patients (21% cholecystitis, 14% recurrent gallstone pancreatitis) at a median time to incidence of 10 months. Seventeen (35%) patients eventually received a postnecrosectomy cholecystectomy, of which 75% required an open procedure.
  
  
  CONCLUSIONS
  Single-stage CCY at the time of pancreatic necrosectomy is safe in selected patients and should be performed if technically feasible to prevent future biliary complications and reduce the need for a subsequent separate, often open, CCY.
authors.affiliation: Department of Surgery, Massachusetts General Hospital, Harvard Medical School, Boston, MA, USA.
authors.forename: Zhi Ven
authors.initials: ZV
authors.lastname: Fong
authors.forename: Miroslav
authors.initials: M
authors.lastname: Peev
authors.forename: Andrew L
authors.initials: AL
authors.lastname: Warshaw
authors.forename: Keith D
authors.initials: KD
authors.lastname: Lillemoe
authors.forename: Carlos
authors.initials: C
authors.lastname: Fernández-del Castillo
authors.forename: George C
authors.initials: GC
authors.lastname: Velmahos
authors.forename: Peter J
authors.initials: PJ
authors.lastname: Fagenholz
mesh_terms: D001649:Bile Duct Diseases / Q000517:prevention & control*; D002763:Cholecystectomy / Q000379:methods*; D003646:Debridement / Q000379:methods*; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D019283:Pancreatitis, Acute Necrotizing / Q000175:diagnosis / Q000601:surgery*; D012189:Retrospective Studies; D013997:Time Factors