SSAT - TIMING MATTERS: EVALUATING THE IMPACT OF EARLY VERSUS DELAYED CHOLECYSTECTOMY ON INFECTIOUS ADVERSE EVENTS IN BILIARY NECROTIZING PANCREATITIS

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TIMING MATTERS: EVALUATING THE IMPACT OF EARLY VERSUS DELAYED CHOLECYSTECTOMY ON INFECTIOUS ADVERSE EVENTS IN BILIARY NECROTIZING PANCREATITIS
Himsikhar Khataniar^*¹, Rahul Karna², Hany Habib¹, Stuart K. Amateau²
¹Internal Medicine, Allegheny General Hospital, Pittsburgh, PA; ²University of Minnesota Twin Cities, Minneapolis, MN

Introduction:
Patients with biliary necrotizing pancreatitis (NP) should undergo cholecystectomy, however, optimal timing of surgery remains a subject of debate. Early cholecystectomy may prevent recurrent biliary events but carries increased risk of postoperative complications, particularly in the presence of peripancreatic collections. Sterile collections may become infected predisposing to infectious adverse events (AEs). Overall, there is limited evidence to guide the timing of cholecystectomy in NP patients.

Methods:
We conducted a retrospective cohort study using the TriNetX database to evaluate the timing of cholecystectomy and its association with postoperative infectious AEs in patients with NP. Patients diagnosed with NP who underwent subsequent cholecystectomy between January 2005 to October 2024 were included. The primary outcome evaluated was overall postoperative infectious AEs within 30 days of surgery, analyzed across time intervals of cholecystectomy: ?4 vs. ?4 weeks, ?6 vs. ?6 weeks, <8 vs. ?8 weeks, ?12 vs. ?12 weeks, ?16 vs. ?16 weeks, and ?20 vs. ?20 weeks. Secondary outcomes included post-surgical cholangitis, infected pancreatic necrosis, sepsis, hospitalization, and all-cause mortality. Propensity score matching (1:1) was performed to account for demographics, BMI, comorbidities including prior pancreatitis, prior surgeries, ERCP procedures and ICU admissions.

Results:
We included 1457 patients with mean age 58 years comprising 47.99% females, who underwent cholecystectomy (laparoscopic:1262; open:164) for biliary NP in our study. Table 1 shows the number of patients undergoing cholecystectomy stratified by timing since surgery. Patients undergoing cholecystectomy at ?12 weeks had higher composite infectious AEs (aOR:2.03, p=0.002) in comparison to ?12 weeks; however, no significant differences were observed for patients undergoing surgery ?16 vs ?16 weeks (p=0.221) (Figure1). Risk of sepsis were significantly higher in patients undergoing surgery ?12 weeks (aOR:3,p:0.003) when compared to ?12 weeks cohort; however, no significant differences were observed for patients undergoing surgery ?16 vs ?16 weeks (p=0.057). Risk of infected necrosis was significantly higher in patients undergoing cholecystectomy ?8 weeks (aOR2.11, p=0.01), however, no significant differences were observed for patients undergoing surgery ?12 vs ?12 weeks (p=0.07). Mortality rates remained low across all intervals.

Conclusion: Our study shows that early (?12 weeks) cholecystectomy following an event of NP increases the risk of adverse events, while delaying surgery beyond 16 weeks reduces postoperative infectious complications without increasing mortality. While our study suggests 16 weeks as optimal timing of surgery, local expertise and risk of recurrent biliary events from delayed surgery must be weighed prior to deciding timing of cholecystectomy.

Table 1: Thirty Day Infectious Adverse Events in Patients Undergoing Cholecystectomy for Necrotizing Biliary Pancreatitis: Analysis at 4, 6, 8, 12, 16, and 20 Weeks Post-Index Presentation of Necrotizing Pancreatitis

Figure 1: Forest Plots for Adverse Events and Sepsis Following Cholecystectomy in Necrotizing Biliary Pancreatitis Patients

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