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Cholecystectomy and sphincterotomy in patients with mild acute biliary pancreatitis in Sweden 1988 - 2003: a nationwide register study
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
Umeå University, Faculty of Medicine, Department of Surgical and Perioperative Sciences, Surgery.
Umeå University, Faculty of Medicine, Department of Public Health and Clinical Medicine, Epidemiology and Global Health.
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2009 (English)In: BMC Gastroenterology, ISSN 1471-230X, Vol. 9, 80- p.Article in journal (Refereed) Published
Abstract [en]

BACKGROUND: Gallstones represent the most common cause of acute pancreatitis in Sweden. Epidemiological data concerning timing of cholecystectomy and sphincterotomy in patients with first attack of mild acute biliary pancreatitis (MABP) are scarce. Our aim was to analyse readmissions for biliary disease, cholecystectomy within one year, and mortality within 90 days of index admission for MABP.

METHODS: Hospital discharge and death certificate data were linked for patients with first attack acute pancreatitis in Sweden 1988-2003. Mortality was calculated as case fatality rate (CFR) and standardized mortality ratio (SMR). MABP was defined as acute pancreatitis of biliary aetiology without mortality during an index stay of 10 days or shorter. Patients were analysed according to four different treatment policies: Cholecystectomy during index stay (group 1), no cholecystectomy during index stay but within 30 days of index admission (group 2), sphincterotomy but not cholecystectomy within 30 days of index admission (group 3), and neither cholecystectomy nor sphincterotomy within 30 days of index admission (group 4).

RESULTS: Of 11636 patients with acute biliary pancreatitis, 8631 patients (74%) met the criteria for MABP. After exclusion of those with cholecystectomy or sphincterotomy during the year before index admission (N = 212), 8419 patients with MABP remained for analysis. Patients in group 1 and 2 were significantly younger than patients in group 3 and 4. Length of index stay differed significantly between the groups, from 4 (3-6) days, (representing median, 25 and 75 percentiles) in group 2 to 7 (5-8) days in groups 1. In group 1, 4.9% of patients were readmitted at least once for biliary disease within one year after index admission, compared to 100% in group 2, 62.5% in group 3, and 76.3% in group 4. One year after index admission, 30.8% of patients in group 3 and 47.7% of patients in group 4 had undergone cholecystectomy. SMR did not differ between the four groups.

CONCLUSION: Cholecystectomy during index stay slightly prolongs this stay, but drastically reduces readmissions for biliary indications.

Place, publisher, year, edition, pages
BioMed Central, 2009. Vol. 9, 80- p.
Keyword [en]
gallstone pancreatitis, endoscopic sphincterotomy, surgical-management, 1st attack, guidelines, cholelithiasis, classification, cholangitis
National Category
Gastroenterology and Hepatology
URN: urn:nbn:se:umu:diva-30598DOI: 10.1186/1471-230X-9-80ISI: 000271901500001PubMedID: 19852782OAI: diva2:284853

The study was supported by the County Councils of Northern Sweden (Norrlandstingens regionforbund). The funding body had no influence on study design; in the collection, analysis and interpretation of data; in the writing of the manuscript; and in the decision to submit the manuscript for publication.

Available from: 2010-01-08 Created: 2010-01-08 Last updated: 2013-08-22Bibliographically approved
In thesis
1. Complicated gallstone disease in Sweden 1988-2006: a register study
Open this publication in new window or tab >>Complicated gallstone disease in Sweden 1988-2006: a register study
2011 (English)Doctoral thesis, comprehensive summary (Other academic)
Abstract [en]

Background The gallstone prevalence in the western world is 10-20%. Most gallstones are silent, but symptoms and complications appear in 20-40%. The incidence of symptom development in patients with silent gallstones is 2-4% per year. The indication for surgical (including endoscopic) treatment of gallstones is symptoms of certain magnitude, and no contraindications. During the past three decades an intense technical development in imaging (ultrasound, computerised tomography and magnetic resonance imaging), endoscopic therapy, and surgery has taken place. The aim of this thesis is to scrutinize changes in management of complicated gallstone disease on a population-based level, using national register data. Have the new methods improved the treatment of acute pancreatitis, common bile duct stones and acute gallbladder disease?

Methods Data is collected from National Patient Register (NPR) run by The Swedish National Board of Health and Welfare. NPR collects discharge data from every admission from every Swedish hospital. Mortality is calculated as standardised mortality ratio (SMR) using age-, gender-, and calendar year specific survival estimates. We have studied both general trends in admissions and treatment alternatives and outcomes in defined patient cohorts. Length of hospital stay, readmission, and mortality has been used as proxy indicators of the effectiveness of treatment strategies used.

Results During the study period mortality in acute pancreatitis (SMR within 90 days of admission) improved and hospital stay for all patients with acute pancreatitis decreased. Cholecystectomy rate at or shortly after index stay for mild acute biliary pancreatitis increased from 14.5 % to 22.7 %. Of all patients with acute pancreatitis 68.4 % of the patients had no aetiological diagnosis in the register. The incidence of bile duct interventions increased 27.8% from 1988 through 2006. The favoured treatment of bile duct stones changed from open choledocholithectomy to endoscopic sphincterotomy with stone extraction during the same period. However, in 2006, still 19.6% of bile duct interventions for stones were performed as choledochotomy and in the great majority of these cases as open surgery. This indicates a continuing need of education in open bile duct surgery. Mean hospital stay for treatment of common bile duct stones decreased significantly (4.5 days) during the period studied. The mortality (SMR) diminished although without statistical significance during the time period, and there was no significant difference in SMR between choledochotomy and endoscopic sphincterotomy. For acute gallbladder disease a moderate increase of admissions occurred from 1988 through 2006. The relation between acute cholecystectomies versus all cholecystectomies did not change during this period. Of all patients admitted with acute gallbladder disease 32.3 % were cholecystectomised during their first hospital stay, whereas 20.3 % underwent elective cholecystectomy and 6.1 % emergency cholecystectomy within two years of first admission. 41.4 % of patients were not operated on for gallbladder disease within two years of first admission with this diagnosis. Mortality from first admission and 90 days onwards was elevated three-fold during the entire period without time trend, without statistical difference between age groups, and between patients who had cholecystectomy at first admission or later.

Conclusion During the audit period treatment of acute pancreatitis improved. However, etiological classification and timing of cholecystectomy in mild acute biliary pancreatitis fell below accepted guidelines. Interventions on the common bile duct for gallstone disease increased significantly. Common bile duct clearance has been separated from cholecystectomy, and cholecystectomy often not done. Only one third of all patients with acute gallbladder disease underwent cholecystectomy at first admission. There is room for improvement in treatment of complicatedgallstone disease, and, gallstone surgeons still need good knowledge in open biliary surgery.

Place, publisher, year, edition, pages
Umeå: Umeå universitet, 2011. 67 p.
Umeå University medical dissertations, ISSN 0346-6612 ; 1424
Gallstone disease, acute pancreatitis, acute biliary pancreatitis, common bile duct stones, acute cholecystitits, acute gallbladder disease, cholecystectomy, ERCP, endoscopic papillotomy, choledochotomy
National Category
Research subject
urn:nbn:se:umu:diva-43279 (URN)978-91-7459-218-4 (ISBN)
Public defence
2011-05-20, Sal B, 9 tr, byggnad 1D, Norrlands universitetssjukhus, Umeå, 13:00 (Swedish)
Available from: 2011-04-28 Created: 2011-04-26 Last updated: 2012-10-01Bibliographically approved

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