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When gallbladder can’t be removed, ERCP can limit recurrent pancreatitis

NEW YORK (Reuters Health) – If patients with gallstone pancreatitis must leave the hospital without the recommended first-line cholecystectomy, therapeutic endoscopic retrograde cholangiopancreatography (ERCP) can reduce the risk of recurrence by as much as half or more compared to no treatment at all, a new study has found.

“Any patient that comes in with acute gallstone pancreatitis, we recommend that they have their gallbladder removed during the first hospitalization,” Dr. Philip Haigh, Assistant Chief of the Department of Surgery at Kaiser Permanente Los Angeles Medical Center in Los Angeles, who led the study, told Reuters Health by phone.

“If they can’t have that operation, then at least have an ERCP,” Dr. Haigh says.

In a paper online July 24 in JAMA Surgery, Dr. Haigh and his team report on patients treated from 1995 to 2010 at 14 Kaiser Permanente Southern California hospitals.

They found 7,970 patients diagnosed with acute gallstone pancreatitis. After excluding patients who had previous pancreatitis, cholecystectomy or less than eight weeks of follow-up, 5,754 patients remained.

From those individuals the researchers identified their study group of 1,119 patients with gallstone pancreatitis who did not undergo cholecystectomy. That group included 802 patients who had no intervention at all and 317 who had ERCP to open the ducts where stones may be lodged.

On average, patients stayed in the hospital for four days if they had ERCP, and three days if they had no intervention (p<0.001).

During a median 2.3 years of follow up, 163 patients developed recurrent gallstone pancreatitis.

The recurrence rate was 78.2% after ERCP (26 patients), compared to 17.1% among those with no intervention at all (137 patients).

The Cox proportional hazards model found that ERCP was independently associated with a lower risk of recurrent pancreatitis compared to no intervention (hazard ratio 0.45).

Among patients who did have recurrence, the median interval after first diagnosis was 11.3 months after ERCP and 10.1 months among those with no intervention.

On Kaplan Meier analysis, estimated recurrence risks in the ERCP group were 5.2% at one year, 7.4% at two years, and 11.1% at five years. In the no-intervention group, the risk estimates were 11.3% at one year, 16.1% at two years, and 22.7% at five years.

Other factors associated with recurrence were Charlson Comorbidity Index score and a stay in the intensive care unit. Age, sex, and Ranson score on admission were not associated with recurrence, however.

For comparison, 3,447 patients from the same pool had a cholecystectomy when they were first hospitalized, and 187 (5.4%) had a recurrence within a median of 9.7 months.

Also, among 1,135 patients had an elective cholecystectomy after discharge from the hospital, 82 (7.2%) had a recurrence before their procedure within a median of seven months.

A third set of 53 patients had an elective ERCP after discharge (no cholecystectomy), and 26 (49.1%) had a recurrence before their procedure within a median of 9.6 months.

“Our study focused on recurrent pancreatitis, but we also found that patients had other complications during follow-up, including acute cholecystitis, choledocholithiasis, and cholangitis,” the authors wrote.

“The point the authors make is, if there’s a reason you can’t do cholecystectomy, you should consider doing ERCP and sphincterotomy,” said Dr. Wayne Overby, a surgeon at the University of North Carolina at Chapel Hill, who was not involved in the study.

Overall, Dr. Overby told Reuters Health, “I think it’s a great paper and they do a good job of putting their findings in context.”

But, he added, doctors and patients should bear in mind that ERCP is not necessarily an easy or even a less complicated option than the gold standard treatment of cholecystectomy.

“They’re both a pretty big deal,” Dr. Overby said.


JAMA Surgery 2013.