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Do Cholecystectomy First in Patients with Intermediate Risk for Choledocholithiasis

July 18, 2014

Do Cholecystectomy First in Patients with Intermediate Risk for Choledocholithiasis

  1. Chris E. Forsmark, MD

This approach resulted in fewer hospital stays and fewer procedures compared with performing preoperative endoscopic investigation of the common bile duct.

  1. Chris E. Forsmark, MD

Current guidelines recommend preoperative endoscopic retrograde cholangiopancreatography (ERCP) or endoscopic ultrasound (EUS) prior to cholecystectomy in patients with a high risk for concomitant choledocholithiasis (i.e., patients with cholangitis, jaundice, or a visible common bile duct [CBD] stone on noninvasive imaging). In patients with low risk for choledocholithiasis (i.e., patients with uncomplicated gallstone pancreatitis), proceeding directly to cholecystectomy is recommended, although preoperative ERCP continues to be utilized inappropriately in this setting. However, in patients with a moderate risk for CBD stones, most guidelines provide no specific treatment recommendations.

In the current trial, investigators randomized 100 patients to a strategy of cholecystectomy with intraoperative cholangiography, followed by ERCP if CBD stones were visualized, or a strategy of preoperative EUS (followed by ERCP if CBD stones were identified) followed by cholecystectomy. Participants had moderate risk for CBD stones, defined as abdominal pain or acute cholecystitis, elevated liver chemistries (≥2 times the upper limit of normal of aspartate aminotransferase or alanine aminotransferase levels), and gallstones visible on ultrasonography. Patients with cholangitis, pancreatitis, bilirubin level >4 mg/dL, or visible CBD stones were excluded. The primary outcome was length of stay. Secondary outcomes were number of procedures, morbidity, mortality, and quality of life at 1 and 6 months after discharge.

Compared with the preoperative-EUS group, the direct-cholecystectomy group had a shorter hospital stay (median days, 5 vs. 8), required fewer procedures (magnetic resonance cholangiopancreatography, EUS, and ERCP), had a similar complication rate, and had similar quality of life. No deaths occurred. Twenty percent of patients in each group were found to have choledocholithiasis. All ERCPs were successful in extracting CBD stones.

Comment

Patients with moderate risk for CBD stones are better managed by cholecystectomy initially, with subsequent ERCP reserved for those with a positive intraoperative cholangiogram or other clinical or radiographic features suggesting a retained CBD stone.

  • Disclosures for Chris E. Forsmark, MD at time of publication Editorial boards American Journal of Gastroenterology; Gut; Pancreas Leadership positions in professional societies American Gastroenterological Association (Chair, Pancreas Section)

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