Among patients with mild biliary pancreatitis, does same-admission cholecystectomy reduce the risk of recurrent pancreatitis and its complications including mortality compared to 30 day interval cholecystectomy?
In patients with mild biliary panceratitis, same admission cholecystectomy safely reduces the risk of recurrent pancreatitis and its sequelae.
Gallstones account for up to 40% of cases of acute pancreatitis . Cholecystectomy greatly reduces the the risk of recurrent gallstone pancreatitis. The PONCHO trial demonstrated that performing the cholecystectomy during the same hospitalization greatly reduced the risk of 30 day readmission, predominantly from recurrent pancreatitis (9% to 2%). It further demonstrated no adverse effect of early timing (similar rates of bile duct leak, difficulty of operation, operating time, and length of stay). This trial added to previous studies that demonstrate that safety and efficacy of same admission cholecystectomy   , and data by the same group indicates it is cost effective 
Caution should be taken in generalizing these results to patients who either have local complications of pancreatitis (which can increase the difficulty of cholecystectomy) or have significant comorbidities that may require medical optimization. Same admission cholecystectomy may be harmful in moderate/severe acute biliary pancreatitis, peripancreatic fluid collections, or pseudocysts. 
- World Society of Emergency Surgery 2019 Guidelines recommended laparoscopic cholecystectomy for mild acute gallstones pancreatitis (1A), even when ERCP and sphincterotomy are performed (1B). They recommended patients with peripancreatic fluid collections should undergo interval cholecystectomy (2C). 
- Setting: 23 hospitals in the Netherlands
- Enrollment: N=266, 136 interval cholecystectomy, 128 same admission cholecystectomy
- 447 excluded
- Dec 2010 - August 2013
- Follow-up: 6 month in interval group
- Analysis: intention-to-treat
- Primary outcome: Combined endpoint of acute readmission for gallstone-related complication or mortality
- 1st episode of pancreatitis
- Ultrasound evidence of gallstones/sludge/CBD dilation
- Pain controlled without opiates
- Tolerating a regular diet
- ASA class I to III
- Organ failure
- local pancreatic complication (fluid collection)
- CRP > 100
- Median data shown for same-admission cholecystectomy group (N= 128)
- Age (years) 53 (38-66)
- Female sex 76 (59%)
- BMI 27 (24-32)
- History of upper abdominal surgery 6%
- History of gallstone colic 30%
- History of cholecystitis 2%
- History of diabetes 9%
- ASA class
- I 34%
- 2 56%
- 3 10%
- ERCP sphincterotomy prior to randomization 27%
- CRP mg/L prior to randomization
- days of admission before randomization 5(3-8)
- Days between randomization and cholecystectomy 1
- Note this value is 27 (26-29) in the interval group
- Interval Cholecystectomy
- Interval cholecystectomy scheduled between 25-30 days from discharge
- No intraoperative cholangiograms were performed
Comparisons are interval cholecystectomy vs. Same-admission cholecystectomy.’’
- Mortality or readmission for gallstone related complications
- 23 (17%) vs. 6 (5%) (RR 0.28, 95% CI 0.12-0.66, P=0.002)
- Recurrent pancreatitis
- 9% vs. 2% (RR 0.27, 95% CI .08-0.92, P =.03)
- 2% vs. 0%
- Choledocholithiasis requiring ERCP
- 2% vs. 1% (RR 0.53 95% CI .05-5.79, P =1.0)
- Gallstone colic
- 5% vs. 2% (RR 0.3, 95% CI .06-1.43, P = .17)
- Reported colics during waiting period
- 51% vs. 3% (RR .06, 95% CI .02-0.19, P = .03)
- Median Difficulty of cholecystectomy on visual analogue scale
- 6 (range 4-7) vs. 6 (range 4-7) P=0.7:
- Operating time, length of stay, and need for ICU admission did not differ between the two groups
- Endoscopic sphincterotomy did not show an interaction with primary outcome.
- Among patients who had undergone prior sphincterotomy
- Mortality or readmission for gallstone related complications:
- 17%(7/42) vs. 3%(1/35) (P=.07)
- age < 75 and ≥75 years did not show an interaction effect with the primary outcome
- Safety endpoints including cystic duct leakage, need for reoperation and blood transfusion were the same between both groups (1% in all cases)
- In the interval cholecystectomy group the need for additional intervention was 2% (radiologic intervention)
- In the same admission cholecystectomy group, 1 person needed additional surgical intervention, and 1 person needed additional endoscopic intervention
- 1 person in the interval cholecystectomy group suffered a pulmonary embolism
- There was 1 mortality in the same admission cholecystectomy group (ischemic stroke after hospitalization
- Patients were generally healthy and mild cases (ASA III or lower, tolerating a diet with opioid medications), unclear extrapolation to sicker patients
- Dutch Digestive Disease Foundation (no role in analysis)
- Yadav D & Lowenfels AB Trends in the epidemiology of the first attack of acute pancreatitis: a systematic review. Pancreas 2006. 33:323-30.
- Noel R et al. Index versus delayed cholecystectomy in mild gallstone pancreatitis: results of a randomized controlled trial. HPB (Oxford) 2018. 20:932-938.
- Mueck KM et al. Gallstone Pancreatitis: Admission Versus Normal Cholecystectomy-a Randomized Trial (Gallstone PANC Trial). Ann. Surg. 2019. 270:519-527.
- MOMBAERTS J & [Cystalgias. Brux Med 1950. 30:2047-58.]
- da Costa DW et al. Cost-effectiveness of same-admission versus interval cholecystectomy after mild gallstone pancreatitis in the PONCHO trial. Br J Surg 2016. 103:1695-1703.
- Nealon WH et al. Appropriate timing of cholecystectomy in patients who present with moderate to severe gallstone-associated acute pancreatitis with peripancreatic fluid collections. Ann. Surg. 2004. 239:741-9; discussion 749-51.
- Leppäniemi A et al. 2019 WSES guidelines for the management of severe acute pancreatitis. World J Emerg Surg 2019. 14:27.