Hwang and colleagues1 offer an interesting look into the management of gallstone pancreatitis through the lens of an integrated health care system, Kaiser Permanente Southern California. The Kaiser system (compared with other insurance plans or hospitals) offers a unique opportunity to study this issue. They have a largely closed system offering synchronized care among various health care providers, and fewer patients move in and out of their umbrella of care. Thus, the article by Hwang et al is an important addition to the current literature suggesting that the recurrence of gallstone pancreatitis is all too common.2 Their data also suggest that endoscopic retrograde cholangiopancreatography (ERCP) during the index admission in patients who do not undergo cholecystectomy may be beneficial in preventing recurrent disease. In their cohort of 1119 patients who did not undergo cholecystectomy, 14.6% developed recurrent gallstone pancreatitis and 11.0% developed other issues related to gallstone disease. In patients who underwent ERCP, there was a 50% reduction in recurrent gallstone pancreatitis. Nonetheless, the risk of recurrence after ERCP remains elevated when compared with patients who underwent cholecystectomy (8.2% vs 5.4%, respectively). Accordingly, we agree with the authors that ERCP for the “definitive” management of gallstone pancreatitis3 should still be reserved for patients with a strong contraindication to surgery.
Worhunsky DJ, Visser BC. Gallstone PancreatitisWhy Not Cholecystectomy?. JAMA Surg. 2013;148(9):872. doi:10.1001/jamasurg.2013.3063