Background

Acute pancreatitis is associated with high readmission rates, particularly for presentations with a biliary etiology, where the adult readmission rate has been reported to range from 4-37%. Once considered primarily an adult disease, gallstones are being seen with increasing frequency in pediatric populations. This study aimed to evaluate the impact of cholecystectomy (CCY) and endoscopic retrograde cholangiopancreatography (ERCP) at the index admission on readmission rates in pediatric patients presenting with acute gallstone pancreatitis.

Methods

Hospitalizations in pediatric patients presenting with gallstone pancreatitis from 2016 – 2020 were divided into 3 groups: (1) no CCY or ERCP, (2) ERCP without CCY, and (3) CCY without ERCP. A univariate regression analysis was performed with the readmission rate as the dependent variable and potential confounders as the independent variable. These variables were then adjusted for in a Cox proportional hazards regression analysis. Kaplan-Meier curves were then constructed to compare the hazard ratios for all-cause 60-day readmission rate.

Results

There were 4,778 admissions for gallstone pancreatitis. 24.5% did not undergo CCY or ERCP (mean age 13.8 ± 0.3, female 69%), 6.5% underwent ERCP (mean age 12.8 ± 0.9, female 73%), and 69.1% underwent CCY (mean age 14.5 ± 0.2, female 73%). Among patients who did not receive CCY or ERCP at the index admission, 28.9% were readmitted for biliary pancreatitis and 10.3% for cholelithiasis and choledocholithiasis. No readmissions were attributed to pancreatitis for patients who underwent an ERCP, but 14.3% had cholelithiasis. CCY at the index admission was associated with a significant reduction in readmission rates (aHR 0.21;0.14 – 0.30; p<0.001). In patients with severe gallstone pancreatitis who did not receive CCY but did undergo ERCP, readmission rates were decreased 44.6% vs 16.9%; however, this did not reach statistical significance. Readmission rates among patients with severe pancreatitis were similar between patients who underwent ERCP or CCY (aHR 0.21;0.03 – 1.52;p=0.12). On Kaplan-Meier analysis, CCY had the greatest protective effect among readmissions for gallstone pancreatitis (Figure 1). For patients who received a CCY, the most common reason for readmission was acute pancreatitis at 17.9%, biliary pancreatitis at 11.0%, and pancreatic pseudocyst 10.3%. Length of stay was similar between all three cohorts, and no statistically significant differences were seen on multivariate regression.

Conclusion

Similar to adult cohorts, cholecystectomy at the index admission significantly decreases readmission rates for pediatric patients with gallstone pancreatitis and should be strongly considered prior to discharge. No readmissions were seen for pancreatitis in patients who underwent ERCP, and ERCP should be considered in patients with choledocholithiasis.

Matthew Clifton

Appearances