A.P. Ng1, T.N. Coaston1, J.E. Hadaya1, Z. Gao1, C. De Virgilio2, P. Benharash1 1David Geffen School Of Medicine, University Of California At Los Angeles, Surgery, Los Angeles, CA, USA 2Harbor-UCLA Medical Center, Surgery, Torrance, CA, USA
Introduction: In the absence of cholangitis, the role of common bile duct evaluation (CBDE) via preoperative ERCP or intraoperative cholangiogram (IOC) in gallstone pancreatitis remains controversial. Clearance of CBD stones has been suggested to reduce risk of recurrent pancreatitis or biliary complications. We aimed to examine the association of CBDE with index outcomes and readmission following cholecystectomy for gallstone pancreatitis.
Methods: All adults undergoing cholecystectomy for gallstone pancreatitis in the 2014-2021 Nationwide Readmissions Database were identified. Records with concomitant cholangitis, neoplasms, or liver transplantation were excluded. Study cohorts were stratified based on use of CBDE, either through preoperative ERCP or IOC. Multivariable mixed regressions were developed to examine the association of CBDE with in-hospital mortality, complications, conversion to open, length of stay (LOS), costs, and 90-day readmission. Repair of bile duct injury (BDI) within the 1-year surveillance period was identified, excluding those with CBD exploration.
Results: Of 352,295 patients undergoing cholecystectomy for gallstone pancreatitis, 45.8% underwent CBDE (15.9% preoperative ERCP, 29.9% IOC). Over the study period, utilization of CBDE significantly decreased from 58.8% to 37.9% (p<0.001). Compared to patients without CBDE, CBDE patients were more commonly privately-insured and treated at high-volume hospitals. Of note, CBDE patients experienced significantly lower mortality (No CBDE 0.6% vs ERCP 0.3% vs IOC 0.3%, p<0.001). Compared to IOC, ERCP patients had greater rates of conversion to open (4.8 vs 3.9%, p<0.001), BDI repair (0.3 vs 0.2%, p=0.01), and complications (17.7 vs 15.3%, p<0.001), primarily gastrointestinal and renal. In addition, patients with ERCP accrued greater LOS (5 vs 4 days, p<0.001) and total hospitalization costs ($18,900 vs $15,400, p<0.001). CBDE patients experienced significantly lower rates of 90-day readmission, which were similar between types of CBDE (No CBDE 11.3% vs ERCP 9.0% vs IOC 9.5%, p<0.001). After adjustment, while mortality was comparable, IOC remained associated with decreased odds of complications (AOR 0.88 [95% CI 0.83-0.93]), conversion (0.78 [0.72-0.85]), and BDI repair (0.66 [0.49-0.89]) relative to ERCP. Compared to No CBDE, ERCP and IOC were both associated with over 20% reduced odds of 90-day readmission (ERCP 0.75 [0.71-0.80] vs IOC 0.81 [0.77-0.85]).
Conclusions: The use of CBDE, particularly IOC, was associated with significantly reduced mortality, conversion to open, resource use, and readmission following cholecystectomy. Patients with gallstone pancreatitis may benefit from routine IOC to decrease risk of recurrent biliary disease.