Gallstone pancreatitis in older patients: Are we operating enough?

• Published in: Surgery 2011-09, Vol.150 (3), p.515-525
• Main Authors: Trust, Marc D., BS, Sheffield, Kristin M., PhD, Boyd, Casey A., MD, Benarroch-Gampel, Jaime, MD, Zhang, Dong, PhD, Townsend, Courtney M., MD, Riall, Taylor S., MD, PhD
• Format: Article
• Language: English
• Subjects: Aged; Aged, 80 and over; Biological and medical sciences; Cholangiopancreatography, Endoscopic Retrograde - methods; Cholecystectomy, Laparoscopic - methods; Cholecystectomy, Laparoscopic - statistics & numerical data; Cohort Studies; Databases, Factual; Female; Follow-Up Studies; Gallstones - complications; Gallstones - diagnostic imaging; Gallstones - mortality; Gallstones - surgery; Gastroenterology. Liver. Pancreas. Abdomen; General aspects; Geriatric Assessment; Guideline Adherence; Humans; Kaplan-Meier Estimate; Liver. Biliary tract. Portal circulation. Exocrine pancreas; Male; Medical sciences; Medicare - statistics & numerical data; Multivariate Analysis; Other diseases. Semiology; Outcome Assessment (Health Care); Pancreatitis - diagnostic imaging; Pancreatitis - etiology; Pancreatitis - mortality; Pancreatitis - surgery; Patient Readmission - statistics & numerical data; Postoperative Complications - epidemiology; Postoperative Complications - physiopathology; Practice Guidelines as Topic; Proportional Hazards Models; Recurrence; Retrospective Studies; Risk Factors; Sphincterotomy, Endoscopic; Surgery; Survival Rate; Treatment Outcome; United States
• ISSN: 0039-6060; 1532-7361
• DOI: 10.1016/j.surg.2011.07.072

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. Conclusion 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.