title: Unrecognized necrosis at same admission cholecystectomy for pancreatitis increases organ failure and infected necrosis.
abstract: OBJECTIVE
  Guidelines recommend same admission cholecystectomy (SAC) in the management of mild acute gallstone pancreatitis (AGP) with a recent randomized trial supporting this recommendation. However, the push for early cholecystectomy will lead a subset of patients with evolving, unrecognized necrotizing pancreatitis (NP) to undergo laparoscopic cholecystectomy (LC) with unknown consequences. With concerns about potentially serious outcomes, we studied the outcomes in patients with unrecognized NP who underwent SAC and identified predictors of unrecognized NP at the time of SAC.
  
  
  METHODS
  Retrospective study of patients who appeared to have mild AGP but subsequently discovered to have unrecognized NP after SAC (study group). Outcomes were compared to a similar cohort with necrotizing AGP who did not undergo SAC (control group 1). Predictors for unrecognized NP at the time of SAC were identified through logistic regression using a second control group with truly mild AGP undergoing SAC.
  
  
  RESULTS
  Patients in the study group (N = 46) undergoing SAC demonstrated higher rates of persistent organ failure (p = 0.0003), infected necrosis (p = 0.02), and length of hospital stay (p = 0.049) compared to a similar group (N = 48) with necrotizing AGP who did not undergo SAC. Persistent SIRS (p < 0.0001) and WBC >12 × 109/L (p < 0.0001) on the day of cholecystectomy were associated with evolving/unrecognized NP.
  
  
  CONCLUSIONS
  Unrecognized NP at the time of SAC is associated with increased rates of subsequent persistent organ failure, infected necrosis, and length of hospital stay. Persistent leukocytosis and SIRS at the time of proposed cholecystectomy are predictive of unrecognized NP and should prompt contrast enhanced CT prior to proceeding with LC.
authors: Division of Gastroenterology, University of California San Diego Health Sciences, 9500 Gilman Drive (MC 0956), La Jolla, CA 92093, United States.
authors: Wilson Tak-Yu
authors: WT
authors: Kwong
authors: Division of Gastroenterology, Mayo Clinic Rochester, 2001st St SW, Rochester, MN 55902, United States. Electronic address: vege.santhi@mayo.edu.
authors: Santhi Swaroop
authors: SS
authors: Vege
mesh_terms: D000328:Adult; D000368:Aged; D000369:Aged, 80 and over; D016022:Case-Control Studies; D002763:Cholecystectomy; D057210:Delayed Diagnosis / Q000009:adverse effects*; D003951:Diagnostic Errors / Q000009:adverse effects*; D005260:Female; D006801:Humans; D007239:Infections / Q000209:etiology*; D016015:Logistic Models; D008297:Male; D008875:Middle Aged; D009102:Multiple Organ Failure / Q000209:etiology*; D010195:Pancreatitis / Q000175:diagnosis / Q000601:surgery; D019283:Pancreatitis, Acute Necrotizing / Q000150:complications / Q000175:diagnosis* / Q000601:surgery; D012189:Retrospective Studies; D012307:Risk Factors; D012720:Severity of Illness Index
keywords: Gallstone pancreatitis; Infected necrosis; Laparoscopic cholecystectomy; Pancreas; SIRS; Timing