Early Versus Late Cholecystectomy After Clearance of Common Bile Duct Stones by Endoscopic Retrograde Cholangiopancreatography: A Prospective Randomized Study

Early versus delayed laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography: A meta-analysis

PURPOSES

Patients with cholecysto- and choledocholithiasis usually undergo endoscopic retrograde cholangiopancreatography (ERCP)/-endoscopic sphincterotomy followed by laparoscopic cholecystectomy (LC). However, differences in the timing of LC after the ERCP may alter the post-operative outcomes. The aim of this study was to compare the effect of early (≤3 days) or delayed LC (>3 days) following ERCP on the post-operative outcomes.

METHODS

A comprehensive search of the 3 databases PubMed, EMBASE and the Cochrane Library was performed. Articles related to LC at different time-points after ERCP were retrieved. Dichotomous and continuous outcomes were analyzed by risk ratio (RR) and mean difference, and RevMan was used to analyze each group.

RESULTS

A total of 7 studies, including 5 randomized controlled studies and 2 retrospective studies, involved a total of 711 patients. There were 332 patients in early LC group and 379 in delayed LC group. The conversion rate was lower in the early LC group compared to the delayed LC group (RR 0.38, 95% confident interval 0.19 to 0.74, P = .005, I2 = 0%). Early LC resulted in a shorter operation time (RR -6.2, 95% CI -27.2 to -5.2, P = .004, I2 = 97%) and fewer complications (RR 0.48, 95% CI 0.29 to 0.79, P = .004, I2 = 17%). Subgroup analysis found that there were no significant differences in the conversion rate (RR 0.61, 95% CI 0.25 to 1.45, P = .26, I2 = 0%) or complications between the early LC group and the delayed group who underwent LC after 1 month.

CONCLUSION

Early LC after ERCP is the preferred treatment for patients with concurrent cholecysto- and choledocholithiasis due to improved clinical outcomes as compared to those who undergo delayed LC.

The role of cholecystectomy following endoscopic sphincterotomy and bile duct stone removal

INTRODUCTION

Choledocholithiasis is common, with patients usually treated with endoscopic retrograde cholangiopancreatography (ERCP) and subsequent cholecystectomy to remove the presumed source of common bile duct (CBD) stones. However, previous investigations into the management of patients following ERCP have focused on recurrent CBD stones, negating the risks of cholecystectomy. This article appraises the role of cholecystectomy following successful endoscopic clearance of bile duct stones.

METHODS

Patients undergoing ERCP and CBD clearance for choledocholithiasis at St James's University Hospital January 2015-December 2018 were included. Patients were divided into those who received cholecystectomy and those managed non-operatively. Readmissions, operative morbidity, mortality and treatment costs were investigated.

RESULTS

Eight hundred and forty-four patients received ERCP and CBD clearance with 3.9 years follow-up. Two hundred and nine patients underwent cholecystectomy with 15% requiring complex surgery. Three hundred and seventy-three patients were non-operatively managed. Unplanned readmissions occurred in 15% following ERCP, mostly within two years. There was no difference in readmissions between the two groups. Accounting for the entire patient pathway, non-operative management was less expensive.

CONCLUSIONS

The majority of patients do not require readmission following ERCP for CBD stones, and cholecystectomy did not reduce the risk of readmission. Few patients have recurrent CBD stones, but complex biliary surgery is frequently required. Routine cholecystectomy following ERCP needs to be re-evaluated and a more stratified approach to future risk developed.

Meta-analysis of the timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in patients with cholecystolithiasis and choledocholithiasis

Endoscopic retrograde cholangiopancreatography (ERCP) combined with laparoscopic cholecystectomy plays an important role in the treatment of cholecystolithiasis combined with choledocholithiasis; however, there is no unified standard for the interval of ERCP before laparoscopic cholecystectomy. We conducted a literature search, data extraction and meta-analysis on this topic. Twelve articles with 1142 patients were included, including 567 patients in the E-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed within 72 h after ERCP) and 575 patients in the D-laparoscopic cholecystectomy group (laparoscopic cholecystectomy performed 72 h after ERCP). The results showed that: compared with the D-laparoscopic cholecystectomy group, the duration of cholecystectomy was shorter in the E-laparoscopic cholecystectomy group [weighted mean difference (WMD) = -16.18, 95% confidence interval (CI) (-22.27 to -10.08), P  < 0.00001], and the postoperative hospitalization was shorter [WMD = -1.24, 95% CI (-1.98 to -0.50), P  < 0.0001]. There were fewer complications [odds ratio (OR) = 0.25, 95% CI (0.39-0.62), P  < 0.0001], lower conversion rate [OR = 0.39, 95% CI (0.21-0.71), P  = 0.002], lower high sensitivity C-reactive protein at 3 days after surgery [WMD = -8.76, 95% CI (-12.59 to -4.93), P  < 0.00001], and fewer neutrophils in the ampulla of gallbladder specimen [WMD = -4.21, 95% CI (-4.55 to -3.88), P < 0.00001]. Therefore, in the treatment of cholecystolithiasis combined with choledocholithiasis by laparoscopic cholecystectomy within 72 h after ERCP, the degree of inflammation before and after surgery is less, the operation time and hospital stay are shortened, the postoperative complications and the conversion rate are reduced, which is a more appropriate time for surgery.

Comparison of different time intervals between laparoscopic cholecystectomy to endoscopic retrograde cholangiopancreatography for patients with cholecystolithiasis complicated by choledocholithiasis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is a common strategy for treatment of patients with gallstones with co-existing stones in the common bile duct (CBD). We conducted this study to compare the effect of different time intervals between ERCP and LC.

Methods

A total of 214 patients who underwent elective LC after ERCP for gallstones and CBD stones between January 2015 and May 2021 were retrospectively reviewed. We compared the hospital stay, operation time, perioperative morbidity, and conversion rate to open cholecystectomy, according to the interval between ERCP and ERCP and LC, namely, one day, 2–3 days, and 4 days or more. A generalized linear model was used to analyze the differences among the groups for outcomes.

Results

There were a total of 214 patients with 52, 80, and 82 patients in group 1, group 2, and group 3 respectively. These groups did not differ significantly in terms of major complications or conversion to open surgery (p = 0.503 and p = 0.358, respectively). The generalized linear model showed that operation times in group 1 and group 2 were similar (odds ratio (OR) 0.144, 95% confidence interval (CI) 12.597, 8.511, p = 0.704), while operation time was significantly longer in group 3 than in group 1 (OR 4.005, 95% CI, 0.217, 20.837, p = 0.045). Post-cholecystectomy hospital stay was similar among the three groups, while post-ERCP hospital stay was significantly longer in group 3 compared with group 1.

Conclusion

We recommend that LC be performed within three days after ERCP to reduce operating time and hospital stay.

Timing of laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography in cholelithiasis patients: A systematic review and meta-analysis

There are many variations and unclear definitions of the appropriate timing of laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP), and there is still a lack of consistency about the appropriate timing. Inappropriate timing can be associated with serious comorbidity and can affect the patients. This meta-analysis was conducted to assess the operative outcomes and morbidity to provide a benefit to the patients based on the best timing of LC after ERCP. Randomized controlled trials (RCTs) and retrospective studies were identified from the PubMed and Scopus databases from inception to July 2021. A meta-analysis was performed to estimate the treatment effects on operative outcomes and morbidity. Four RCTs and four retrospective studies met our inclusion criteria. A meta-analysis indicated that patients who received LC after ERCP on the same day or within 72 hours had about 0.354 days shorter length of hospital stay with a shorter operative time of about 0.111-1.835 minutes and a lower risk of complications around 37%-73%. Our evidence suggests that the appropriate timing of LC after ERCP is either the same day or within 72 hours for treating cholelithiasis patients based on the severity of disease.

Is early laparoscopic cholecystectomy after clearance of common bile duct stones by endoscopic retrograde cholangiopancreatography superior?: A systematic review and meta-analysis of randomized controlled trials

BACKGROUND

With medical advancement, common bile duct stones were treated by endoscopic retrograde cholangiopancreatography (ERCP), considered the standard treatment. However, ERCP might induce complications including pancreatitis and cholecystitis that could affect a subsequent laparoscopic cholecystectomy (LC), leading to conversion to open cholecystectomy perioperative complications. It is not yet known whether or not the time interval between ERCP and LC plays a role in increasing conversion rate and complications. Bides, in the traditional sense, after ERCP, for avoiding edema performing LC was several weeks later. Even no one study could definite whether early laparoscopic cholecystectomy after ERCP affected the prognosis or not clearly.

OBJECTIVE

Comparing some different surgical timings of LC after ERCP.

METHOD

Searching databases consist of all kinds of searching tools, such as Medline, Cochrane Library, Embase, PubMed, etc. All the included studies should meet the demands of this meta-analysis. In all interest outcomes below, we took full advantage of RevMan5 and WinBUGS to assess; the main measure was odds ratio (OR) with 95% confidence. Moreover, considering the inconsistency of the specific time points in different studies, we set a subgroup to analyze the timing of LC after ERCP. For this part, Bayesian network meta-analysis was done with WinBUGS.

RESULT

In the pool of conversion rate, the result suggested that the early LC group was equal compared with late LC (OR = 0.68, I2 = 0%, P = .23). Besides, regarding morbidity, there was no significant difference between the 2 groups (OR = 0.74, I2 = 0%, P = .26). However, early LC, especially for laparoscopic-endoscopic rendezvous that belonged to performing LC within 24 hours could reduce the post-ERCP pancreatitis (OR = 0.16, I2 = 29%, P = .0003). Considering early LC included a wide time and was not precise enough, we set a subgroup by Bayesian network, and the result suggested that performing LC during 24 to 72 hours was the lowest conversion rate (rank 1: 0%).

CONCLUSION

In the present study, LC within 24 to 72 hours conferred advantages in terms of the conversion rate, with no recurrence of acute cholecystitis episodes.

Optimal Timing of Cholecystectomy for Patients with Concurrent Acute Cholecystitis and Acute Cholangitis after Successful Biliary Drainage by Interventional Endoscopic Retrograde Cholangiopancreatography

Background: Concurrent acute cholecystitis and acute cholangitis is a unique clinical situation. We tried to investigate the optimal timing of cholecystectomy after adequate biliary drainage under this condition. Methods: From January 2012 to November 2017, we retrospectively screened all in-hospitalized patients undergoing endoscopic retrograde cholangiopancreatography (ERCP) and then identified patients with concurrent acute cholecystitis and acute cholangitis from the cohort. The selected patients were stratified into two groups: one-stage intervention (OSI) group (intended laparoscopic cholecystectomy at the same hospitalization) vs. two-stage intervention (TSI) group (interval intended laparoscopic cholecystectomy). Interrogated outcomes included recurrent biliary events, length of hospitalization, and surgical outcomes. Results: There were 147 patients ultimately enrolled for analysis (OSI vs. TSI, 96 vs. 51). Regarding surgical outcomes, there was no significant difference between the OSI group and TSI group, including intraoperative blood transfusion (1.0% vs. 2.0%, p = 1.000), conversion to open procedure (3.1% vs. 7.8%, p = 0.236), postoperative complication (6.3% vs. 11.8%, p = 0.342), operation time (118.0 min vs. 125.8 min, p = 0.869), and postoperative days until discharge (3.37 days vs. 4.02 days, p = 0.643). In the RBE analysis, the OSI group presented a significantly lower incidence of overall RBE (5.2% vs. 41.2%, p < 0.001) than the TSI group. Conclusions: Patients with an initial diagnosis of concurrent acute cholecystitis and cholangitis undergoing cholecystectomy after ERCP drainage during the same hospitalization period may receive some benefit in terms of clinical outcomes.

[Temporal sequence of bile duct clearance with simultaneous cholecystolithiasis or choledocholithiasis-Preoperative, intraoperative or postoperative?]

Approximately 10% of patients with symptomatic cholecystolithiasis also have choledocholithiasis. The probability of this can be estimated on the basis of sonographic and laboratory chemistry parameters. If the probability is high, endoscopic retrograde cholangiography (ERC) or cholangiopancreatography (ERCP) should be performed and if the probability is low, cholecystectomy can be performed without further diagnostics. If the findings are equivocal, further work-up should be performed to detect or exclude choledocholithiasis by endoscopic ultrasound (EUS) or magnetic resonance cholangiopancreatography (MRCP). If choledocholithiasis is detected, it can be treated by ERC preoperatively, intraoperatively or postoperatively or alternatively by laparoscopic cholangiography. Regarding the temporal sequence, there is no clear advantage of a specific time point; however, considering the high availability of ERCP in German-speaking countries, preoperative clearance of choledocholithiasis seems reasonable. With respect to the time interval between clearance of choledocholithiasis and cholecystectomy, a number of multicenter studies and a meta-analysis have shown that a short time interval or a procedure during the same period of hospitalization is advantageous.

Attenuation around the gallbladder on plain abdominal computed tomography as a predictor of surgical difficulty in laparoscopic cholecystectomy

PURPOSE

This study examined whether abdominal plain computed tomography (CT) can predict surgical difficulty in acute cholecystitis.

METHODS

We retrospectively analyzed 84 consecutive patients who underwent laparoscopic cholecystectomy for acute cholecystitis between January 2015 and December 2018. We distinguished three degrees of surgical difficulty based on the operative time and blood loss: difficult, both ≥120 minutes and ≥ 100 mL, respectively (n = 27); moderate, either ≥120 minutes or ≥ 100 mL, respectively (n = 30); and easy, both <120 minutes and < 100 mL, respectively (n = 27). We calculated the attenuation around the gallbladder on CT before surgery and compared the values among the three groups.

RESULTS

Mean age, albumin levels, C-reactive protein levels, and the CT attenuation around the gallbladder (P < .001) were significantly different between groups. The surgical difficulty was unrelated to the timing of surgery. The postoperative complications were more frequent in operations more than 72 hours after disease onset (P = .04) and with CT attenuation around the gallbladder of ≥1.4 (P = .036).

CONCLUSION

High attenuation around the gallbladder on plain CT predicted a high surgical difficulty of laparoscopic cholecystectomy. We recommend measuring the CT attenuation around the gallbladder in patients with acute cholecystitis.

Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis

Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.

Systematic review and meta-analysis of gallstone disease treatment outcomes in early cholecystectomy versus conservative management/delayed cholecystectomy

Background

The effectiveness of early cholecystectomy for gallstone diseases treatment is uncertain compared with conservative management/delayed cholecystectomy.

Aims

To synthesise treatment outcomes of early cholecystectomy versus conservative management/delayed cholecystectomy in terms of its safety and effectiveness.

Design

We systematically searched randomised control trials investigating the effectiveness of early cholecystectomy compared with conservative management/delayed cholecystectomy. We pooled the risk ratios with a 95% CI, also estimated adjusted number needed to treat to harm.

Results

Of the 40 included studies for systematic review, 39 studies with 4483 patients are included in meta-analysis. Among the risk ratios of gallstone complications, pain (0.38, 0.20 to 0.74), cholangitis (0.52, 0.28 to 0.97) and total biliary complications (0.33, 0.20 to 0.55) are significantly lower with early cholecystectomy. Adjusted number needed to treat to harm of early cholecystectomy compared with conservative management/delayed cholecystectomy are, for pain 12.5 (8.3 to 33.3), biliary pancreatitis >1000 (50–100), common bile duct stones 100 (33.3 to 100), cholangitis (100 (25–100), total biliary complications 5.9 (4.3 to 9.1) and mortality >1000 (100 to100 000).

Conclusions

Early cholecystectomy may result in fewer biliary complications and a reduction in reported abdominal pain than conservative management.

PROSPERO registration number

2020 CRD42020192612.

Delayed cholecystectomy following endoscopic retrograde cholangio-pancreatography is not associated with worse surgical outcomes

BACKGROUND

There is no universal consensus on the optimal timing of cholecystectomy following endoscopic retrograde cholangio-pancreatography (ERCP). This study aims to evaluate the effect of time delay and post-ERCP complications on cholecystectomy outcomes.

MATERIALS AND METHODS

All patients who underwent pre-op ERCP for concurrent cholelithiasis and choledocholithiasis between January 2009 and August 2019 at University Hospitals Plymouth, UK, were included. Patients who underwent single-stage cholecystectomy and common bile duct exploration were excluded from the study. Based on the delay to cholecystectomy, the patients were divided into early (within 2 weeks), intermediate (2-6 weeks) and late (> 6 weeks) groups. The operative outcomes between the three groups were compared.

RESULTS

We included 444 patients in the study, with 62 (14%), 90 (20%) and 292 (66%) patients in the early, intermediate and late groups, respectively. The median duration from ERCP to cholecystectomy was 75 days. There was no statistically significant difference in the conversion-to-open rate, bile leak rate or retained stones between the three groups. The median post-operative hospital stay (PHS) was 2, 2 and 1 day (P = 0.005) in the early, intermediate and late groups, respectively. The readmission rate was significantly more in the delayed group (3.2%, 11.1% and 13.7%; P = 0.05). Patients who suffered post-ERCP complications had a significantly longer PHS (4 vs 1 day, P = 0.001) and had higher conversion-to-open rate (16 vs 4.5%, P = 0.04).

CONCLUSION

Delayed cholecystectomy following ERCP is not associated with worse peri-operative outcomes and can facilitate more day-case surgery. However, early cholecystectomy can significantly reduce readmissions with gallstone-related symptoms and its associated hospital stay. Post-ERCP complications lead to a difficult cholecystectomy.

Outcomes of same admission cholecystectomy and endoscopic retrograde cholangiopancreatography for common bile duct stones: A post hoc analysis of an Eastern Association for the Surgery of Trauma multicenter study

BACKGROUND

The optimal timing for cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) for common bile duct (CBD) stones is unknown. We hypothesized that a delay between procedures would correlate with more biliary complications and longer hospitalizations.

METHODS

We prospectively identified patients who underwent same admission cholecystectomy after ERCP for CBD stones from 2016 to 2019 at 12 US medical centers. The cohort was stratified by time between ERCP and cholecystectomy: ≤24 hours (immediate), >24 to ≤72 hours (early), and >72 hours (late). Primary outcomes included operative duration, postoperative length of stay, (LOS), and hospital LOS. Secondary outcomes included rates of open conversion, CBD explorations, biliary complications, and in-hospital complications.

RESULTS

For the 349 patients comprising the study cohort, 33.8% (n = 118) were categorized as immediate, 50.4% (n = 176) as early, and 15.8% (n = 55) as late. Rates of CBD explorations were lower in the immediate group compared with the late group (0.9% vs. 9.1%, p = 0.01). Rates of open conversion were lower in the immediate group compared with the early group (0.9% vs. 10.8%, p < 0.01) and in the immediate group compared with the late group (0.9% vs. 10.9%, p < 0.001). On a mixed-model regression analysis, an immediate cholecystectomy was associated with a significant reduction in postoperative LOS (β = 0.79; 95% confidence interval, 0.65-0.96; p = 0.02) and hospital LOS (β = 0.68; 95% confidence interval, 0.62-0.75; p < 0.0001).

CONCLUSION

An immediate cholecystectomy following ERCP correlates with a shorter postoperative LOS and hospital LOS. Rates of CBD explorations and conversion to open appear more common after 24 hours.

LEVEL OF EVIDENCE

Therapeutic, level III.

Laparoscopic management of intra-hepatic gallbladder perforation

Intra-hepatic perforation of the gallbladder (GB) leading to hepatic abscess is a serious and rare complication of cholecystitis, with very few sporadically reported cases in the literature. Hence, there is no standard approach to treat it. A thorough radiological evaluation with computed tomography and endoscopic retrograde cholangiopancreatography is necessary before proceeding with surgery in such cases. An early laparoscopic intervention to perform a sub-total cholecystectomy with drain placement is enough to treat both cholecystitis and liver abscess in a definitive manner. While previous reports have advocated an open surgery, our series demonstrates that early laparoscopic management is a safe and suitable approach in such cases.

Effectiveness of a quality improvement collaborative in reducing time to surgery for patients requiring emergency cholecystectomy

Background

Acute gallstone disease is a high‐volume emergency general surgery presentation with wide variations in the quality of care provided across the UK. This controlled cohort evaluation assessed whether participation in a quality improvement collaborative approach reduced time to surgery for patients with acute gallstone disease to fewer than 8 days from presentation, in line with national guidance.

Methods

Patients admitted to hospital with acute biliary conditions in England and Wales between 1 April 2014 and 31 December 2017 were identified from Hospital Episode Statistics data. Time series of quarterly activity were produced for the Cholecystectomy Quality Improvement Collaborative (Chole‐QuIC) and all other acute National Health Service hospitals (control group). A negative binomial regression model was used to compare the proportion of patients having surgery within 8 days in the baseline and intervention periods.

Results

Of 13 sites invited to join Chole‐QuIC, 12 participated throughout the collaborative, which ran from October 2016 to January 2018. Of 7944 admissions, 1160 patients had a cholecystectomy within 8 days of admission, a significant improvement (P < 0·050) from baseline performance. This represented a relative change of 1·56 (95 per cent c.i. 1·38 to 1·75), compared with 1·08 for the control group. At the individual site level, eight of the 12 Chole‐QuIC sites showed a significant improvement (P < 0·050), with four sites increasing their 8‐day surgery rate to over 20 per cent of all emergency admissions, well above the mean of 15·3 per cent for control hospitals.

Conclusion

A surgeon‐led quality improvement collaborative approach improved care for patients requiring emergency cholecystectomy.

One-stage laparoscopic procedure versus two-stage procedure in the management of common bile duct stones in patients aged 75 and more

INTRODUCTION

The management strategy for common bile duct stones (CBD) in patients over 75years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients.

MATERIAL AND METHODS

This study included eighty-two patients over 75years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n=40) or by sequential endoscopy and surgery (ES group, n=42).

RESULTS

Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P=0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (>3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively.

CONCLUSION

The "surgery alone" attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledocholithiasis.

Role of Cholecystectomy After Endoscopic Sphincterotomy in the Management of Choledocholithiasis in High-risk Patients: A Systematic Review and Meta-Analysis

BACKGROUND

Endoscopic retrograde cholangiography and endoscopic sphincterotomy (ES) with subsequent cholecystectomy is the standard of care for the management of patients with choledocholithiasis. There is conflicting evidence in terms of mortality reduction, prevention of complications specifically biliary pancreatitis and cholangitis with the use of early cholecystectomy particularly in high-risk surgical and elderly patients.

AIMS

We conducted this systematic review and meta-analysis of randomized controlled trials to compare the early cholecystectomy versus wait and watch strategy after ES.

METHODS

We searched Medline, Scopus, Web of Science, and Cochrane database for randomized controlled trials comparing the 2 strategies in the management of choledocholithiasis after ES. Our primary outcome of interest was difference in mortality. We evaluated several secondary outcomes including difference in development of acute pancreatitis, biliary colic and cholecystitis, cholangitis and recurrent jaundice, nonbiliary adverse events, and length of hospital stay. Risk ratios (RR) were calculated for categorical variables and difference in means was calculated for continuous variables. These were pooled using random effects model.

RESULTS

Seven studies with 916 patients (455 cholecystectomy group and 461 wait and watch group) were included in the meta-analysis. Pooled RR with 95% confidence interval for mortality was 1.43 (0.93-2.18), I=9%. In the high-risk patient group, pooled RR was 1.39 (0.64-3.03) and in low-risk population pooled RR was 1.53 (0.79-2.96). Pooled RR for acute pancreatitis was 1.64 (0.46-5.81) with no heterogeneity. There was no difference in the rate of acute pancreatitis patients based on high-risk versus low-risk patients. Pooled RR for occurrence of biliary colic and cholecystitis during follow-up was 9.82 (4.27-22.59), I=0%. Pooled RR for cholangitis and recurrent jaundice was 2.16 (1.14-4.07), I=0%. However, there was no difference in the rate of cholangitis between the 2 groups in low-risk patients. Length of stay was shorter in the wait and watch group with a pooled mean difference was -2.70 (-4.71, -0.70) with substantial heterogeneity.

CONCLUSIONS

Although we found no difference in mortality between the 2 strategies after ES, laparoscopic cholecystectomy should be recommended as it is associated with lower rates of subsequent recurrent cholecystitis, cholangitis, and biliary colic down the road even in high-risk surgical patients.

Evaluation of risk factors for recurrent primary common bile duct stone in patients with cholecystectomy

OBJECTIVES

Recurrence of primary common bile duct (CBD) stone commonly occurs after complete removal of CBD stones in patients with cholecystectomy. This study aimed to investigate potential risk factors for the recurrence of primary CBD stones after endoscopic treatment.

MATERIALS AND METHODS

Between January 2005 and December 2015, the endoscopic retrograde cholangiopancreatography (ERCP) database of our medical center was retrospectively reviewed; information regarding eligible patients who had recurrent CBD stones with a history of previous cholecystectomy was collected. The characteristics of the patients, CBD stone, CBD and ERCP-related factors were analyzed.

RESULTS

The recurrence rate of CBD stone was 18.5% (115/622) after endoscopic treatment in patients with cholecystectomy. In univariate analysis, the number of CBD stones (≥2), CBD stone diameter (≥10 mm), stone composition, stone consistency, CBD diameter (≥15 mm), bile duct dilatation pattern, sharp bile duct angulation (<145°), balloon dilatation, large balloon (>12 mm) dilatation, endoscopic mechanical lithotripsy, endoscopic sphincterotomy, and endoscopic papillary balloon dilatation alone method were significant between the non-recurrence and recurrence groups. However, in multivariate analysis (based on the binary logistic regression method), the number of CBD stones (≥2) (adjusted odds ratio [AOR] 3.232; 95% confidence interval [CI] 1.344-7.773; p = .009), cholesterol stone (AOR 2.824; 95% CI 1.175-6.786; p =.02) and sharp bile duct angulation (<145°) (AOR 2.462; 95% CI 1.062-5.711; p = .036) were independent risk factors of CBD stone recurrence after cholecystectomy.

CONCLUSIONS

CBD stone number (≥2), cholesterol stone and sharp bile duct angulation (<145°) are associated with recurrent common bile duct stones after cholecystectomy.