Taibah University

Journal of Taibah University Medical Sciences (2014) 9(4), 322e327

Journal of Taibah University Medical Sciences

www.sciencedirect.com

Original Article

Early versus interval cholecystectomy after mild acute gallstone

pancreatitis: A 10 year experience in central Saudi Arabia

Hamad Hadi Al-Qahtani, FRCS

Department of Surgery, College of Medicine, King Saud University, Riyadh, Kingdom of Saudi Arabia

Received 4 April 2014; revised 28 May 2014; accepted 25 June 2014; Available online 16 September 2014

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دعبلوخدلاسفنلالخركبملاةرارملالاصئتساةمالسةسارد:ثحبلافادهألدعمىلعزيكرتلاعم،ةرارملاىصحنعجتانلافيفخلاداحلاسايركنبلاباهتلاىفشتسملايفةماقإلاةدمو،ةيوارفصلاتاباصإلاو،ةحوتفمةحارجىلإليوحتلا.ةرارملاىصحبةطبترملاثداوحلاراركتو

ىضرملاعيمجليعجررثأبةيبطلاتالجسلاتعجوروتسرُد:ثحبلاقرطيفةرارملاىصحنعجتانلافيفخلاداحلاسايركنبلاباهتلاصيخشتبنيمونملانيبامةرتفلايف،ةيدوعسلاةيبرعلاةكلمملا،ضايرلا،ةيبطلادوعسكلملاةنيدمدنعضارعألاو،سنجلاو،رمعلابقلعتياميفم٢٠١٢ربمسيدوم٢٠٠٣رياني،ةرارملالاصئتساتيقوتو،ةيعاعشلاروصلاو،ةيربخملاجئاتنلاو،روضحلا،ةحوتفملاةحارجلاىلإليوحتلاو،ةيلمعلاءانثأفيزنلاو،ةيوارفصلاتاباصإلاوةطبترملاثداوحلاراركتو،ىفشتسملابةماقإلاةدمو،نيحارجلاو،ةيلمعلاةدمو.تايفولالدعمو،ةرارملاىصحب

متاضيرم٣٨٦نيبنمركبملاةرارملالاصئتسالاضيرم٢٦٧عضخ:جئاتنلاةيلمعلاتمتدقو،ةرارملاىصحببسبفيفخلاداحلاسايركنبلاباهتلابمهميونت١١ـلةحوتفملاةحارجللليوحتلاىلإةجاحلاتعد.تالاحلانم٢٥٦ددعلحاجنبةحجانةيظفحتةجلاعمدعباوجرخدقف)١١٩¼ددعلا(ىضرملاةيقبامأ.اضيرمةرارملاتلصؤتسا.اعوبسأ١٢-٦دعباقحالةرارملالاصئتسانوكينأىلعتناكو.ةحوتفملاةحارجلاىلإمهنمنينثايتيلمعتلوحتو,اضيرم٨٣ـلاقحالثداوحلاراركتناكامنيب،ركبملاةرارملالاصئتسادنعريثكبرصقأةماقإلاةدمكانهنكيمل.اقحالةرارملالاصئتسادنعريثكبىلعأةرارملاىصحبةطبترملاتافعاضمو،ةحوتفملاةحارجلاىلإليوحتلالدعميفظوحلمفالتخا.ةيوارفصلا

Corresponding address: Associate Professor & Consultant

neral and Hepatobiliary Surgeon, Department of Surgery, Col-

e of Medicine, King Saud University, P.O. Box 7805, Riyadh

72, Kingdom of Saudi Arabia.

E-mail: Hamad_qah@hotmail.com

r review under responsibility of Taibah University.

Production and hosting by Elsevier

8-3612 � 2014 Taibah University.duction and hosting by Elsevier Ltd. All rights reserved.

p://dx.doi.org/10.1016/j.jtumed.2014.06.001

داحلاسايركنبلاباهتلادعبركبملاةرارملالاصئتسانأدجو:تاجاتنتسالاةيمهأتاذةدايزدجويالو.لوخدلاسفنلالخلمعاذإنمآءارجإوهفيفخلاعقاولايف.ةيوارفصلاةانقلاتاباصإوأةحوتفملاةحارجلاىلإليوحتلالدعميفىفشتسملابةماقإلاةدميفةيمهأيذضافخناىلإركبملاةرارملالاصئتساىدأ.ةرارملاىصحبةطبترملاثداوحلاراركتيفكلذكو

ةرارملالاصئتسا;ةرارملاىصحببسبسايركنبلاباهتلا:ةيحاتفملاتاملكلاقحاللاةرارملالاصئتسا;ركبملا

Abstract

Objectives: To study the safety of early cholecystectomy

(EC) during the index admission following acute mild

gallstone pancreatitis, focusing on conversion rate, biliary

injuries, length of hospital stay and recurrent gallstone

related events.

Methods: Medical records of all patients who were

admitted with a diagnosis of acute mild gallstone

pancreatitis at King Saud Medical City, Riyadh,

Kingdom of Saudi Arabia between January 2003 and

December 2012 were studied retrospectively and reviewed

in relation to age, gender, presenting symptoms, labora-

tory findings, imaging studies, timing of cholecystectomy,

biliary injury, intraoperative bleeding, conversion to open

surgery, duration of surgery, operating surgeons, hospital

stay, recurrent gallstone related events and mortality.

Results: Out of 386 patients admitted with acute mild

gallstone pancreatitis, 267 patients underwent EC which

was successfully performed in 256 cases. Conversion to

open cholecystectomy was needed in 11 cases. The rest of

the patients (n ¼ 119) were discharged after successfulconservative treatment for interval cholecystectomy (IC)

after 6e12 weeks. IC was performed on 83 patients, two

were converted to open cholecystectomy. Hospital stay

was significantly shorter in the EC (P < 0.0001) while the

mailto:Hamad_qah@hotmail.comhttp://crossmark.crossref.org/dialog/?doi=10.1016/j.jtumed.2014.06.001&domain=pdfwww.sciencedirect.comhttp://dx.doi.org/10.1016/j.jtumed.2014.06.001http://dx.doi.org/10.1016/j.jtumed.2014.06.001http://dx.doi.org/10.1016/j.jtumed.2014.06.001

Cholecystectomy in mild gallstone pancreatitis 323

recurrent gallstone related events were significantly

higher in IC (P < 0.0001). There was no significant dif-

ference in conversion rate (P ¼ 0.567), and biliary com-plications (P ¼ 0.663).

Conclusion: EC following acute mild gallstone pancrea-

titis was found to be a safe procedure when performed

during the index admission. There was no significant in-

crease in conversion rate or bile duct injuries. In fact, EC

resulted in significant reduction in the hospital stay as

well as in the recurrent gallstone related events.

Keywords: Early cholecystectomy; Gallstone pancreatitis;

Interval cholecystectomy

� 2014 Taibah University.Production and hosting by Elsevier Ltd. All rights reserved.

Introduction

Gallstones and biliary sludge accounted for 30e55% ofacute pancreatitis in the West,1 whereas in Saudi Arabia theincidence of all cases of pancreatitis amounts to 68.5%.2

The risk of subsequent attacks for patients recovering from

the first attack of acute gallstone pancreatitis is 30-foldhigher than general population.3 Further attacks can beprevented by cholecystectomy and bile duct stones clearance

once the acute stage of the disease has settled. However theoptimal timing of cholecystectomy after mild gallstonepancreatitis remains unclear. This retrospective study was

conducted to follow up these patients who underwent earlycholecystectomy (EC) during the index admission andinterval cholecystectomy (IC) after discharge of patients

with acute mild gallstone pancreatitis over the previous 10years. The study focuses on operation time, conversion rate,complications of the procedure, length of hospital stay andrecurrent gallstone related events.

Materials and Methods

In this retrospective study, the medical records of patientswho were admitted with a diagnosis of acute gallstonepancreatitis at King SaudMedical City, Riyadh, Kingdom of

Saudi Arabia between January 2003 and December 2012were retrieved. The diagnosis of mild acute gallstonepancreatitis was based on the presence of upper abdominalpain, a serum amylase level of >500 U/l (25e115 U/l),

Table 1: Comparison of gallstone related events in patients who

underwent EC and IC for acute mild gallstone pancreatitis.

EC (n ¼ 119) IC (n ¼ 267) P-valueGallstone related

events (n)

21 (17.65%) 3 (1.12%) P < 0.0001a

a By Chi-square test.

H.H. Al-Qahtani324

obstructive jaundice ¼ 7, acute cholecystitis ¼ 2, acutepancreatitis ¼ 9). They all underwent successful LC duringthe re-admission time. Eighty three patients were re-admitted

and underwent IC, three of whom were converted to opencholecystectomy due to difficult dissection and unclearanatomy (Figure 1).

Figure 1: Flowchart showing

The conversion rate was 4.1% and 3.6% in patients whounderwent EC and IC respectively. In patients who under-

went EC, there were three cystic duct bile leakage, whichwere managed by endoscopic temporary common bile ductstenting. In patients who underwent IC, there was one

complete transection of common hepatic duct which wastreated by hepaticojejunostomy during the index surgery.Intraoperative bleeding from the operative site was docu-

mented in 32 and 4 patients who underwent EC and ICrespectively. However, no patient needed blood transfusionor conversion to open surgery to control the bleeding(Figure 2). The length of surgery in patients who underwent

EC was 65.1 � 1.9 min (range 45e72 min) while it was60.5 � 2.1 min (range 51e72) in patients who underwentIC. However, in patients who underwent conversion

to open cholecystectomy, the operation time was

the patients distribution.

4.13.6

12

4.8

1.12 1.2 1.12

17.65

0

3

6

9

12

15

18

21

%

Conversion rate Intraoperativebleeding

Biliarycomplications

Gallstone relatedevents (n)

ECIC

Figure 2: Comparison of patients who underwent EC and IC for

acute mild gallstone pancreatitis.

Table 2: Characteristics and comparison of patients who un-

derwent EC and IC for acute mild gallstone pancreatitis.

EC (n ¼ 267) IC (n ¼ 83) P-valueGender

Male 75 (28%) 27 (32.5%) 0.437a

Female 192 (72%) 56 (67.5%)

Age 43.2 � 9.8 44.1 � 8.8 0.455cOperative time (min) 65.1 � 1.9 60.5 � 2.1 0.534cConversion rate 11 (4.1%) 3 (3.6%) 0.567b

Intraoperative bleeding 32 (12.0%) 4 (4.8%) 0.061a

Biliary complications 3 (1.12%) 1 (1.2%) 0.663b

Hospital stay (day) 5.4 � 1.2 10.4 � 1.5 P < 0.0001ca By Chi-square test.b By Fisher’s exact test.c By Student t-test for independent groups.

Cholecystectomy in mild gallstone pancreatitis 325

155.7 � 2.5 min (range 150e162 min) with much difficulty indissection and identification of anatomy in Calot’s triangle.The length of hospital stay was 5.4 � 1.2 days for patientswho underwent EC, and 10.4 � 1.5 days for patients whounderwent IC (Figure 3) (Table 2). All patients whounderwent EC or IC were operated on or supervised byconsultant surgeons with almost similar experience in LC.

Sixteen consultant surgeons were involved in themanagement of the included patients in this study. Nomortality has been reported in this series. Ninety three out

of the total patients (n ¼ 386) underwent ERCP þ ESwithin 72 h from admission time. One group was submittedto LC during the index admission (n ¼ 76), the other group(n ¼ 17) was discharged for DLC. Neither group presentedwith gallstone related events.

Discussion

It is generally agreed that the transient or persistentobstruction of the ampulla of Vater by biliary calculi is theinstigating factor for acute gallstone pancreatitis. Althoughthe clinical course of acute gallstone pancreatitis is often self-

limited, it can be associated with significant morbidity andeven mortality (up to 9%).6 Therefore, the management ofacute gallstone pancreatitis includes timely gallbladder

surgery as well as evaluation and clearance of CBD. Aftersevere pancreatitis, it is advisable to delay cholecystectomy

0

10

20

30

40

50

60

70

80

Age Hospital Stay (day) Operative time (minute)

Mean ± SD

ECIC

Figure 3: Comparison of patients who underwent EC and IC for

acute mild gallstone pancreatitis.

until the local and systemic complications have resolved.7

However, in mild gallstone pancreatitis the optimal time ofcholecystectomy is still controversial. Cholecystectomy

during the index admission, as soon as the patient hasrecovered from the attack of acute gallstone pancreatitis,has been recommended by the International Associationof Pancreatology,8 whereas the British Society of

Gastroenterology9 and American GastroenterologyAssociation10 recommend cholecystectomy within 2e4weeks after discharge. This lack of consensus has also been

reflected in several reports from different countries.11e16

There is no unanimity among our institute surgeons aboutthe appropriate timing of cholecystectomy. Most of them

follow the policy of EC during the index admission, whileothers discharge the patient for interval IC after 6 weeks.

Proponents of IC believe that acute pancreatitis inducesedema and more difficult dissection in patients who under-

went cholecystectomy during the index admission. Thus, itpotentially leads to more conversion to open surgery andmore surgical complications such as bile ducts injuries. In a

recent study, Sinha17 concluded that the difficulty indissection of Calot’s triangle is more frequent in IC thanEC during the index admission (42% vs 12%, P < 0.001).In our study, the incidence of biliary complications andconversion to open surgery were higher in EC than IC, butthe incidence did not reach to statistical significance

(P ¼ 0.0663 and P ¼ 0.567 respectively). On the otherhand, surgeons who advocate EC during the indexadmission argue that the patients would be exposed to therisk of severe and potentially fatal recurrent acute gallstone

pancreatitis.18 The policy of EC results in significantreduction in the total length of hospital stay, expenses formedications and hospital costs.12,19,20 This is because EC

provides the opportunity for complete treatment duringone admission, whereas IC requires two admissions, onefor initial conservative treatment of acute pancreatitis and

another admission for IC. In this study, the length ofhospital stay for EC was significantly less (5.4 � 1.2 vs10.4 � 1.5) when compared to patients who underwent IC(P < 0.0001). The operative time was almost the same inpatients who underwent EC and IC. Significantintraoperative bleeding was observed in patients whounderwent EC when compared to IC. However, it did not

lead to conversion to open surgery in any patient. The

H.H. Al-Qahtani326

major disadvantage of IC observed in this study is thatpatients are lost to come back for IC, with the risk of

developing gallstone related events later. In this study, 15patients did not report for IC and were lost to follow up.By adopting a policy of EC, the risk of losing such patients

at risk of gallstone related events can be averted. Severalrecent studies concluded that interval cholecystectomycarries a substantial risk of recurrent bilio-pancreatic

events after discharge and before IC after mild gallstonepancreatitis.21e23 This risk is high even when the IC takesplace within 2 weeks after discharge from the acutepancreatitis.21,24 In the present study, a significant number

of patients (n ¼ 21) were re-admitted with bilio-pancreaticevents before IC, most of them with pancreatitis (n ¼ 10);however, no single case of severe pancreatitis was recorded.

Although EC during the index admission reduces the re-admission with bilio-pancreatic events, this study shows asmall risk of such events after cholecystectomy (n¼ 3). Theseevents are most likely related to retained CBD stones ornewly formed bile duct stones in patients who present withsuch events a month or even years after cholecystectomy.25

Conclusion

In conclusion, EC for patients with acute mild gallstonepancreatitis was found to be a safe procedure when per-

formed during the index admission. There was no significantincrease in conversion rate or bile duct injuries. It alsoresulted in significant reduction in the length of hospital stayas well as in the recurrent bilio-pancreatic gallstone related

events.

Conflict of interest

The author has no conflict of interest to declare.

Acknowledgments

I am grateful to all the consultants in the department ofGeneral Surgery for allowing their patients to be included inthis study. I am also grateful to Dr. Mohammed Waheed

(Senior Registrar of General Surgery), Dr. Kulood Al-Enazi(Senior Registrar of General Surgery), Dr. Malak Al-zahrani(Resident of General Surgery), Dr. Reem Al-Salamah(Resident of General Surgery), and Mr. Amir Marzoog

(Statistician) for helping in conducting, compiling andanalyzing data for this study.

References

1. Yada D, Lowenfels AB. Trends in the epidemiology of the first

attack of acute pancreatitis: a systemic review. Pancreas 2006;

33: 323e330.2. Abu-Eshy SA. Pattern of acute pancreatitis. Saudi Med J 2001;

22: 215e218.

3. Hernandez V, Pascual I, Almela P, Añon R, Herreros B,

Sanchiz V, Minguez M, Benages A. Recurrence of acute gall-

stone pancreatitis and relationship with cholecystectomy or

endoscopic sphincterotomy. Am J Gastroenterol 2004; 99:

2417e2423.

4. Kasimu H, Jakai T, Qilong C, Jielile J. A brief evaluation for

pre-estimating the severity of gallstone pancreatitis. JOP 2009;

10: 147e151.5. Ranson JH, Rifkind KM, Roses DF, Fink SD, Eng K,

Spencer FC. Prognostic signs and the role of operative manage-

ment in acute pancreatitis.SurgGynecolObstet 1974; 139: 69e81.

6. Steinberg W, Tenner S. Acute pancreatitis. N Engl J Med 1994;

330: 1198e1210.

7. Nealon WH, Bawduniak J, Walser EM. Appropriate timing of

cholecystectomy in patients who present with moderate to se-

vere gallstone-associated acute pancreatitis with peripancreatic

fluid collections. Ann Surg 2004; 239: 741e749.

8. Ulh W, Warshaw A, Imrie C, et al. IAP guidelines for the

surgical management of acute pancreatitis. Pancreatology 2002;

2: 565e573.

9. Working Party of the British Society of Gastroenterology, As-

sociation of Surgeons of Great Britain and Ireland, Pancreatic

Society of Great Britain and Ireland, Association of Upper GI

Surgeons of Great Britain and Ireland. UK guidelines for the

management of acute pancreatitis. Gut 2005; 54: 1111e1119.

10. Forsmark CE, Baillie J. AGA Institute technical review on

acute pancreatitis. Gastroenterology 2007; 132: 2022e2044.11. Cameron DR, Goodman AJ. Delayed cholecystectomy for

gallstone pancreatitis: re-admissions and outcomes. Ann R Coll

Surg Engl 2004; 86: 358e362.12. Monkhouse SJ, Court EL, Dash I, Coombs NJ. Two-week

target for laparoscopic cholecystectomy following gallstone

pancreatitis is achievable and cost neutral. Br J Surg 2009; 96:

751e755.13. Sargen K, Kingsnorth AN. Management of gallstone pancre-

atitis: effects of deviation from clinical guidelines. JOP 2001; 2:

317e322.

14. Lankisch PG, Weber-Dany B, Lerch MM. Clinical perspectives

in pancreatology: compliance with acute pancreatitis guidelines

in Germany. Pancreatology 2005; 5: 591e593.

15. Pezzilli R, Uomo G, Gabbrielli A, Zerbi A, Frulloni L, De

Rai P, Castoldi L, Cavallini G, Di Carlo V, ProInf-AISP Study

Group. A prospective multicentre survey on the treatment of

acute pancreatitis in Italy. Dig Liver Dis 2007; 39: 838e846.

16. Nguyen GC, Boudreau H, Jagannath SB. Hospital volume as a

predictor for undergoing cholecystectomy after admission for

acute biliary pancreatitis. Pancreas 2010; 39: 42e47.

17. Sinha R. Early laparoscopic cholecystectomy in acute biliary

pancreatitis: the optimal choice?HPB(Oxford) 2008; 10: 332e335.18. Gullo L, Migliori M, Pezzilli R, Oláh A, Farkas G, Levy P,

Arvanitakis C, Lankisch P, Beger H. An update on recurrent

acute pancreatitis: data from five European countries. Am J

Gastroenterol 2002; 97: 1959e1962.

19. Rosing DK, de Virgilio C, Yaghoubian A, Putnam BA, El

Masry M, Kaji A, Stabile BE. Early cholecystectomy for mild

to moderate gallstone pancreatitis shortens hospital stay. J Am

Coll Surg 2007; 205: 762e766.

20. Aboulian A, Chan T, Yaghoubian A, Kaji AH, Putnam B,

Neville A, Stabile BE, de Virgilio C. Early cholecystectomy

safely decreases hospital stay in patients with mild gallstone

pancreatitis: a randomized prospective study. Ann Surg 2010;

251: 615e619.

21. Bakker OJ, van Santvoort HC, Hagenaars JC, Besselink MG,

Bollen TL, Gooszen HG, Schaapherder AF, Dutch Pancreatitis

Study Group. Timing of cholecystectomy after mild biliary

pancreatitis. Br J Surg 2011; 98: 1446e1454.

22. van Baal MC, Besselink MG, Bakker OJ, van Santvoort HC,

Schaapherder AF, Nieuwenhuijs VB, Gooszen HG, van

Ramshorst B, Boerma D, Dutch Pancreatitis Study Group.

Timing of cholecystectomy after mild biliary pancreatitis: a

systematic review. Ann Surg 2012; 255: 860e866.23. Sandzén B, Haapamäki MM, Nilsson E, Stenlund HC,

Oman M. Cholecystectomy and sphincterotomy in patients

http://refhub.elsevier.com/S1658-3612(14)00062-6/sref1http://refhub.elsevier.com/S1658-3612(14)00062-6/sref1http://refhub.elsevier.com/S1658-3612(14)00062-6/sref1http://refhub.elsevier.com/S1658-3612(14)00062-6/sref1http://refhub.elsevier.com/S1658-3612(14)00062-6/sref2http://refhub.elsevier.com/S1658-3612(14)00062-6/sref2http://refhub.elsevier.com/S1658-3612(14)00062-6/sref2http://refhub.elsevier.com/S1658-3612(14)00062-6/sref3http://refhub.elsevier.com/S1658-3612(14)00062-6/sref3http://refhub.elsevier.com/S1658-3612(14)00062-6/sref3http://refhub.elsevier.com/S1658-3612(14)00062-6/sref3http://refhub.elsevier.com/S1658-3612(14)00062-6/sref3http://refhub.elsevier.com/S1658-3612(14)00062-6/sref3http://refhub.elsevier.com/S1658-3612(14)00062-6/sref4http://refhub.elsevier.com/S1658-3612(14)00062-6/sref4http://refhub.elsevier.com/S1658-3612(14)00062-6/sref4http://refhub.elsevier.com/S1658-3612(14)00062-6/sref4http://refhub.elsevier.com/S1658-3612(14)00062-6/sref5http://refhub.elsevier.com/S1658-3612(14)00062-6/sref5http://refhub.elsevier.com/S1658-3612(14)00062-6/sref5http://refhub.elsevier.com/S1658-3612(14)00062-6/sref5http://refhub.elsevier.com/S1658-3612(14)00062-6/sref6http://refhub.elsevier.com/S1658-3612(14)00062-6/sref6http://refhub.elsevier.com/S1658-3612(14)00062-6/sref6http://refhub.elsevier.com/S1658-3612(14)00062-6/sref7http://refhub.elsevier.com/S1658-3612(14)00062-6/sref7http://refhub.elsevier.com/S1658-3612(14)00062-6/sref7http://refhub.elsevier.com/S1658-3612(14)00062-6/sref7http://refhub.elsevier.com/S1658-3612(14)00062-6/sref7http://refhub.elsevier.com/S1658-3612(14)00062-6/sref8http://refhub.elsevier.com/S1658-3612(14)00062-6/sref8http://refhub.elsevier.com/S1658-3612(14)00062-6/sref8http://refhub.elsevier.com/S1658-3612(14)00062-6/sref8http://refhub.elsevier.com/S1658-3612(14)00062-6/sref9http://refhub.elsevier.com/S1658-3612(14)00062-6/sref9http://refhub.elsevier.com/S1658-3612(14)00062-6/sref9http://refhub.elsevier.com/S1658-3612(14)00062-6/sref9http://refhub.elsevier.com/S1658-3612(14)00062-6/sref9http://refhub.elsevier.com/S1658-3612(14)00062-6/sref9http://refhub.elsevier.com/S1658-3612(14)00062-6/sref10http://refhub.elsevier.com/S1658-3612(14)00062-6/sref10http://refhub.elsevier.com/S1658-3612(14)00062-6/sref10http://refhub.elsevier.com/S1658-3612(14)00062-6/sref11http://refhub.elsevier.com/S1658-3612(14)00062-6/sref11http://refhub.elsevier.com/S1658-3612(14)00062-6/sref11http://refhub.elsevier.com/S1658-3612(14)00062-6/sref11http://refhub.elsevier.com/S1658-3612(14)00062-6/sref12http://refhub.elsevier.com/S1658-3612(14)00062-6/sref12http://refhub.elsevier.com/S1658-3612(14)00062-6/sref12http://refhub.elsevier.com/S1658-3612(14)00062-6/sref12http://refhub.elsevier.com/S1658-3612(14)00062-6/sref12http://refhub.elsevier.com/S1658-3612(14)00062-6/sref13http://refhub.elsevier.com/S1658-3612(14)00062-6/sref13http://refhub.elsevier.com/S1658-3612(14)00062-6/sref13http://refhub.elsevier.com/S1658-3612(14)00062-6/sref13http://refhub.elsevier.com/S1658-3612(14)00062-6/sref14http://refhub.elsevier.com/S1658-3612(14)00062-6/sref14http://refhub.elsevier.com/S1658-3612(14)00062-6/sref14http://refhub.elsevier.com/S1658-3612(14)00062-6/sref14http://refhub.elsevier.com/S1658-3612(14)00062-6/sref15http://refhub.elsevier.com/S1658-3612(14)00062-6/sref15http://refhub.elsevier.com/S1658-3612(14)00062-6/sref15http://refhub.elsevier.com/S1658-3612(14)00062-6/sref15http://refhub.elsevier.com/S1658-3612(14)00062-6/sref15http://refhub.elsevier.com/S1658-3612(14)00062-6/sref16http://refhub.elsevier.com/S1658-3612(14)00062-6/sref16http://refhub.elsevier.com/S1658-3612(14)00062-6/sref16http://refhub.elsevier.com/S1658-3612(14)00062-6/sref16http://refhub.elsevier.com/S1658-3612(14)00062-6/sref17http://refhub.elsevier.com/S1658-3612(14)00062-6/sref17http://refhub.elsevier.com/S1658-3612(14)00062-6/sref17http://refhub.elsevier.com/S1658-3612(14)00062-6/sref18http://refhub.elsevier.com/S1658-3612(14)00062-6/sref18http://refhub.elsevier.com/S1658-3612(14)00062-6/sref18http://refhub.elsevier.com/S1658-3612(14)00062-6/sref18http://refhub.elsevier.com/S1658-3612(14)00062-6/sref18http://refhub.elsevier.com/S1658-3612(14)00062-6/sref19http://refhub.elsevier.com/S1658-3612(14)00062-6/sref19http://refhub.elsevier.com/S1658-3612(14)00062-6/sref19http://refhub.elsevier.com/S1658-3612(14)00062-6/sref19http://refhub.elsevier.com/S1658-3612(14)00062-6/sref19http://refhub.elsevier.com/S1658-3612(14)00062-6/sref20http://refhub.elsevier.com/S1658-3612(14)00062-6/sref20http://refhub.elsevier.com/S1658-3612(14)00062-6/sref20http://refhub.elsevier.com/S1658-3612(14)00062-6/sref20http://refhub.elsevier.com/S1658-3612(14)00062-6/sref20http://refhub.elsevier.com/S1658-3612(14)00062-6/sref20http://refhub.elsevier.com/S1658-3612(14)00062-6/sref21http://refhub.elsevier.com/S1658-3612(14)00062-6/sref21http://refhub.elsevier.com/S1658-3612(14)00062-6/sref21http://refhub.elsevier.com/S1658-3612(14)00062-6/sref21http://refhub.elsevier.com/S1658-3612(14)00062-6/sref21http://refhub.elsevier.com/S1658-3612(14)00062-6/sref22http://refhub.elsevier.com/S1658-3612(14)00062-6/sref22http://refhub.elsevier.com/S1658-3612(14)00062-6/sref22http://refhub.elsevier.com/S1658-3612(14)00062-6/sref22http://refhub.elsevier.com/S1658-3612(14)00062-6/sref22http://refhub.elsevier.com/S1658-3612(14)00062-6/sref22http://refhub.elsevier.com/S1658-3612(14)00062-6/sref23http://refhub.elsevier.com/S1658-3612(14)00062-6/sref23

Cholecystectomy in mild gallstone pancreatitis 327

with mild acute biliary pancreatitis in Sweden 1988e2003: a

nationwide register study. BMC Gastroenterol 2009; 23(9): 80.

24. Ito K, Ito H, Whang EE. Timing of cholecystectomy for biliary

pancreatitis: do the data support current guidelines?

J Gastrointest Surg 2008; 12: 2164e2170.

25. Gloor B, Stahel PF, Müller CA, Worni M, Büchler MW,

Uhl W. Incidence and management of biliary pancreatitis in

cholecystectomized patients. Results of a 7-year study.

J Gastrointest Surg 2003; 7: 372e377.

http://refhub.elsevier.com/S1658-3612(14)00062-6/sref23http://refhub.elsevier.com/S1658-3612(14)00062-6/sref23http://refhub.elsevier.com/S1658-3612(14)00062-6/sref23http://refhub.elsevier.com/S1658-3612(14)00062-6/sref24http://refhub.elsevier.com/S1658-3612(14)00062-6/sref24http://refhub.elsevier.com/S1658-3612(14)00062-6/sref24http://refhub.elsevier.com/S1658-3612(14)00062-6/sref24http://refhub.elsevier.com/S1658-3612(14)00062-6/sref25http://refhub.elsevier.com/S1658-3612(14)00062-6/sref25http://refhub.elsevier.com/S1658-3612(14)00062-6/sref25http://refhub.elsevier.com/S1658-3612(14)00062-6/sref25http://refhub.elsevier.com/S1658-3612(14)00062-6/sref25

Early versus interval cholecystectomy after mild acute gallstone pancreatitis: A 10 year experience in central Saudi ArabiaIntroductionMaterials and MethodsResultsDiscussionConclusionConflict of interestAcknowledgmentsReferences