Cholelithiasis Plus Choledocholithiasis: ERCP First, What Next?
2006; Elsevier BV; Volume: 130; Issue: 1 Linguagem: Inglês
10.1053/j.gastro.2005.12.010
ISSN1528-0012
Autores Tópico(s)Biliary and Gastrointestinal Fistulas
ResumoWhen patients present with the combined problem of gallstones in the gallbladder and bile duct simultaneously, there are 2 questions to answer: (1) what is the best method for clearing the bile duct and (2) what should be done with the gallbladder? The sequential options are (1) laparoscopic cholecystectomy with laparoscopic bile duct exploration; (2) laparoscopic or open cholecystectomy followed by postoperative ERCP; (3) preoperative ERCP followed by cholecystectomy (laparoscopic or open); (4) open cholecystectomy with open exploration of the bile duct; (5) ERCP and no cholecystectomy and, in special circumstances; (6) a range of additional and much less commonly used surgical and nonsurgical techniques such as percutaneous cholecystostomy, percutaneous access to the bile duct including percutaneous cholangioscopy, techniques for Mirizzi syndrome, management of hepatolithiasis and approaches to recurrent stones after biliary and nonbiliary upper gastrointestinal surgery. It is unlikely that one option will be appropriate for all clinical circumstances in all centers in all countries since the variables of disease states, patient demographics and risk stratifications, available endoscopic, radiologic and surgical expertise, patient preferences, and healthcare economics will all have significant influences on practice.In patients with contemporaneous cholelithiasis and choledocholithiasis, it is usually the latter which dominates the acute clinical presentation and leads to intervention for pain, obstructive jaundice, cholangitis, pancreatitis, or any combination thereof. Less commonly, asymptomatic bile duct stones are discovered incidentally on noninvasive imaging for nonbiliary indications, during evaluation of symptomatic cholelithiasis or intraoperatively during cholecystectomy. Since the universal adoption of laparoscopic cholecystectomy as the primary method for treating cholelithiasis in the early 1990s, only a minority of surgeons has mastered the techniques required for laparoscopic trancystic or direct choledochal exploration to treat choledocholithiasis, and there has been some reluctance to convert to open bile duct exploration for this indication. Many will recall that this was often the case for many surgeons even during the era of open cholecystectomy. Since ERCP became the standard approach for acute presentations of choledocholithiasis in the 1980s and with the overall success of endoscopic bile duct clearance, the question of treating cholelithiasis surgically became a secondary issue.While there is evidence that elective and emergent clearance of the bile duct by ERCP1Escourrou J. Cordova J.A. Lazorthes F. Frexinos J. Ribet A. Early and late complications after endoscopic sphincterotomy for biliary lithiasis, with and without the gallbladder ’in situ’.Gut. 1984; 25: 598-602Google Scholar, 2Tanaka M. Ikeda S. Yoshimoto H. Matsumoto S. The long-term fate of the gallbladder after endoscopic sphincterotomy.Am J Surg. 1987; 154: 505-509Google Scholar, 3Davidson B.R. Neoptolemos J.P. Carr-Locke D.L. Endoscopic sphincterotomy for common bile duct calculi in patients with gallbladder in situ considered unfit for surgery.Gut. 1988; 29: 114-120Google Scholar, 4Siegel J.H. Safrany L. Ben-Zvi J.S. Pullano W.E. Cooperman A. Stenzel M. Ramsey W.H. Duodenoscopic sphincterotomy in patients with gallbladders in situ reports of a series of 1272 patients.Am J Gastroenterol. 1988; 83: 1255-1258Google Scholar, 5Hill J. Martin F. Tweeddle D.E.F. Risk of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.Br J Surg. 1991; 78: 554-557Google Scholar, 6Neoptolemos J.P. Carr-Locke D.L. Fossard D.P. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.Br Med J. 1987; 294: 470-474Google Scholar, 7Stiegmann G.V. Goff J.S. Mansour A. Pearlman N. Reveille R.M. Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.Am J Surg. 1992; 163: 227-230Google Scholar, 8Hammarstrom L.E. Holmin T. Stridbeck H. Ihse I. Long-term follow-up of a prospective randomised study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.Br J Surg. 1995; 82: 1516-1521Google Scholar, 9Targarona E.M. Ayuso R.M. Bordas J.M. Ros E. Pros I. Martinez J. Teres J. Trias M. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients.Lancet. 1996; 347: 926-929Abstract Google Scholar had advantages over open bile duct exploration (usually combined with open cholecystectomy) the comparison of ERCP therapy with laparoscopic bile duct clearance is much more equivalent for most stones in the elective setting.10Cuschieri A. Lezoche E. Morino M. Croce E. Lacey A. Toouli J. Faggioni A. Ribeiro V.M. Jakimowicz J. Visa J. Hanna G.B. EAES multicenter prospective randomised trial comparing two-stage versus single-stage management of patients with gallstone disease and ductal calculi.Surg Endosc. 1999; 13: 952-957Google Scholar, 11Boerma D. Rauws E.A. Keulemans Y. Janssen I. Bolweck C.J. Timmer R. Boerma E.J. Obertop H. Huibregtse K. Gouma D.J. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones a randomised trial.Lancet. 2002; 360: 761-765Abstract Full Text Full Text PDF Scopus (251) Google Scholar Unfortunately, this surgical option is not always available and the evidence is therefore tempered by local expertise. Following endoscopic bile duct clearance, the decision to leave the gallbladder in situ and follow the patient expectantly [option (5) above] compared with routine laparoscopic cholecystectomy has been re-examined in the study reported in this issue by Lau et al in an exclusively Chinese population over the age of 60 years treated at the Prince of Wales Hospital, Chinese University of Hong Kong.12Lau J.Y.W. Leow C.-K. Fung T.M.K. Suen B.-Y. Yu L.-M. Lai P.B.S. Lam Y.-H. Ng E.K.W. Lau W.Y. Chung S.S.C. Sung J.J.Y. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients.Gastroenterology. 2006; 130: 96-103Google Scholar This study calls into question data from the past 2 decades which have helped shape endoscopic and surgical practice in certain patients considered high risk for cholecystectomy and it is timely to re-evaluate this algorithm.In the 1980s, the interpretation of several retrospective and fewer prospective series from respected endoscopy centers advocated in favor of a conservative strategy after ERCP bile duct clearance with gallbladder left in situ for patients considered at higher risk for open cholecystectomy.1Escourrou J. Cordova J.A. Lazorthes F. Frexinos J. Ribet A. Early and late complications after endoscopic sphincterotomy for biliary lithiasis, with and without the gallbladder ’in situ’.Gut. 1984; 25: 598-602Google Scholar, 2Tanaka M. Ikeda S. Yoshimoto H. Matsumoto S. The long-term fate of the gallbladder after endoscopic sphincterotomy.Am J Surg. 1987; 154: 505-509Google Scholar, 3Davidson B.R. Neoptolemos J.P. Carr-Locke D.L. Endoscopic sphincterotomy for common bile duct calculi in patients with gallbladder in situ considered unfit for surgery.Gut. 1988; 29: 114-120Google Scholar, 4Siegel J.H. Safrany L. Ben-Zvi J.S. Pullano W.E. Cooperman A. Stenzel M. Ramsey W.H. Duodenoscopic sphincterotomy in patients with gallbladders in situ reports of a series of 1272 patients.Am J Gastroenterol. 1988; 83: 1255-1258Google Scholar, 5Hill J. Martin F. Tweeddle D.E.F. Risk of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.Br J Surg. 1991; 78: 554-557Google Scholar, 6Neoptolemos J.P. Carr-Locke D.L. Fossard D.P. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.Br Med J. 1987; 294: 470-474Google Scholar, 7Stiegmann G.V. Goff J.S. Mansour A. Pearlman N. Reveille R.M. Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.Am J Surg. 1992; 163: 227-230Google Scholar Overall a 10% incidence of biliary events (pain, cholecystitis, empyema of the gallbladder, choledocholithiasis, cholangitis, liver abscess) over 10 years following treatment was often quoted to patients and this was considered acceptable in these mostly elderly populations. Subsequently, however, randomized studies demonstrated a much higher incidence of biliary events in those patients not undergoing post-ERCP open cholecystectomy of up to 28%.8Hammarstrom L.E. Holmin T. Stridbeck H. Ihse I. Long-term follow-up of a prospective randomised study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.Br J Surg. 1995; 82: 1516-1521Google Scholar, 9Targarona E.M. Ayuso R.M. Bordas J.M. Ros E. Pros I. Martinez J. Teres J. Trias M. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients.Lancet. 1996; 347: 926-929Abstract Google Scholar The equation, however, has changed again in the laparoscopic era with different risk stratification and the desire by patients and clinicians to manage gallstone disease in as minimally invasive a manner as possible. It is a straightforward decision to treat the patient with symptomatic cholelithiasis or an obvious gallbladder complication, such as cholecystitis, perforation or empyema, after successful bile duct therapy but the decision to treat cholelithiasis that is essentially asymptomatic after successful endoscopic bile duct clearance therefore depends on the risk of laparoscopic cholecystectomy balanced against the risk of biliary events during conservative management.10Cuschieri A. Lezoche E. Morino M. Croce E. Lacey A. Toouli J. Faggioni A. Ribeiro V.M. Jakimowicz J. Visa J. Hanna G.B. EAES multicenter prospective randomised trial comparing two-stage versus single-stage management of patients with gallstone disease and ductal calculi.Surg Endosc. 1999; 13: 952-957Google Scholar, 11Boerma D. Rauws E.A. Keulemans Y. Janssen I. Bolweck C.J. Timmer R. Boerma E.J. Obertop H. Huibregtse K. Gouma D.J. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones a randomised trial.Lancet. 2002; 360: 761-765Abstract Full Text Full Text PDF Scopus (251) Google Scholar It seems clear that the data of the past no longer apply at least to modern practice in Chinese patients over the age of 60 years in Hong Kong based on the Lau study.12Lau J.Y.W. Leow C.-K. Fung T.M.K. Suen B.-Y. Yu L.-M. Lai P.B.S. Lam Y.-H. Ng E.K.W. Lau W.Y. Chung S.S.C. Sung J.J.Y. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients.Gastroenterology. 2006; 130: 96-103Google Scholar They report a 7% occurrence of biliary events (83% cholangitis, 13% pain) after endoscopic bile duct clearance and laparoscopic cholecystectomy in contrast to 24% (67% cholangitis or jaundice, 24% cholecystitis, and 9% pain) after endoscopic duct clearance and gallbladder in situ. Although their patient recruitment was not consecutive and the very high surgical-risk patients were excluded, these observations are valuable. The only other similar prospective randomized trial came from the Netherlands11Boerma D. Rauws E.A. Keulemans Y. Janssen I. Bolweck C.J. Timmer R. Boerma E.J. Obertop H. Huibregtse K. Gouma D.J. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones a randomised trial.Lancet. 2002; 360: 761-765Abstract Full Text Full Text PDF Scopus (251) Google Scholar where a 47% incidence of biliary events was seen in the expectant gallbladder in situ group compared with none in the group undergoing cholecystectomy. Unlike this Dutch report and older series from the West, however, 70% of the biliary events in the Lau study12Lau J.Y.W. Leow C.-K. Fung T.M.K. Suen B.-Y. Yu L.-M. Lai P.B.S. Lam Y.-H. Ng E.K.W. Lau W.Y. Chung S.S.C. Sung J.J.Y. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients.Gastroenterology. 2006; 130: 96-103Google Scholar were related to the bile duct rather than the gallbladder, and this may imply a fundamental difference in disease behavior between East and West with a higher incidence of primary duct stones compared with the West. This could be used as an argument in favor of continued endoscopic management, which is, of course necessary, but the incidence of biliary events even without cholangitis is still noticeably higher in the gallbladder in situ group. In keeping with all other studies of following patients with gallbladder in situ after endoscopic sphincterotomy,1Escourrou J. Cordova J.A. Lazorthes F. Frexinos J. Ribet A. Early and late complications after endoscopic sphincterotomy for biliary lithiasis, with and without the gallbladder ’in situ’.Gut. 1984; 25: 598-602Google Scholar, 2Tanaka M. Ikeda S. Yoshimoto H. Matsumoto S. The long-term fate of the gallbladder after endoscopic sphincterotomy.Am J Surg. 1987; 154: 505-509Google Scholar, 3Davidson B.R. Neoptolemos J.P. Carr-Locke D.L. Endoscopic sphincterotomy for common bile duct calculi in patients with gallbladder in situ considered unfit for surgery.Gut. 1988; 29: 114-120Google Scholar, 4Siegel J.H. Safrany L. Ben-Zvi J.S. Pullano W.E. Cooperman A. Stenzel M. Ramsey W.H. Duodenoscopic sphincterotomy in patients with gallbladders in situ reports of a series of 1272 patients.Am J Gastroenterol. 1988; 83: 1255-1258Google Scholar, 5Hill J. Martin F. Tweeddle D.E.F. Risk of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.Br J Surg. 1991; 78: 554-557Google Scholar, 6Neoptolemos J.P. Carr-Locke D.L. Fossard D.P. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.Br Med J. 1987; 294: 470-474Google Scholar, 7Stiegmann G.V. Goff J.S. Mansour A. Pearlman N. Reveille R.M. Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.Am J Surg. 1992; 163: 227-230Google Scholar, 8Hammarstrom L.E. Holmin T. Stridbeck H. Ihse I. Long-term follow-up of a prospective randomised study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.Br J Surg. 1995; 82: 1516-1521Google Scholar, 9Targarona E.M. Ayuso R.M. Bordas J.M. Ros E. Pros I. Martinez J. Teres J. Trias M. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients.Lancet. 1996; 347: 926-929Abstract Google Scholar nearly all of the cholecystitis occurred within the first year of follow-up suggesting that early cholecystectomy is logical. There is also an implication that later cholecystectomy is more difficult with a higher open conversion rate. This study, like all others that have examined it, showed no case of gallstone pancreatitis during follow-up after sphincterotomy.How then do we interpret these new data in the setting of current clinical practice in the East and West and with the experience of what has gone before? Where the expertise is available, elective management of cholelithiasis and choledocholithiasis by the laparoscopic approach should be offered. The role for ERCP in the management of acute calculous bile duct disease remains central and optimal. The majority of patients after successful endoscopic bile duct clearance should undergo laparoscopic cholecystectomy as early as possible to reduce the risk of a further biliary event or treat cholecystitis if already present.13Misra M. Schiff J. Rendon G. Rothschild J. Schwaitzberg S. Laparoscopic cholecystectomy after the learning curve what should we expect?.Surg Endosc. 2005; 19: 1266-1271Google Scholar, 14Lau H. Brooks D.C. Contemporary outcomes of ambulatory laparoscopic cholecystectomy in a major teaching hospital.World J Surg. 2002; 26: 1117-1121Google Scholar There will still be a small population of patients, however, considered at high risk for laparoscopic cholecystectomy and, in these, judicious conservative management of the in situ gallbladder is justifiable. When patients present with the combined problem of gallstones in the gallbladder and bile duct simultaneously, there are 2 questions to answer: (1) what is the best method for clearing the bile duct and (2) what should be done with the gallbladder? The sequential options are (1) laparoscopic cholecystectomy with laparoscopic bile duct exploration; (2) laparoscopic or open cholecystectomy followed by postoperative ERCP; (3) preoperative ERCP followed by cholecystectomy (laparoscopic or open); (4) open cholecystectomy with open exploration of the bile duct; (5) ERCP and no cholecystectomy and, in special circumstances; (6) a range of additional and much less commonly used surgical and nonsurgical techniques such as percutaneous cholecystostomy, percutaneous access to the bile duct including percutaneous cholangioscopy, techniques for Mirizzi syndrome, management of hepatolithiasis and approaches to recurrent stones after biliary and nonbiliary upper gastrointestinal surgery. It is unlikely that one option will be appropriate for all clinical circumstances in all centers in all countries since the variables of disease states, patient demographics and risk stratifications, available endoscopic, radiologic and surgical expertise, patient preferences, and healthcare economics will all have significant influences on practice. In patients with contemporaneous cholelithiasis and choledocholithiasis, it is usually the latter which dominates the acute clinical presentation and leads to intervention for pain, obstructive jaundice, cholangitis, pancreatitis, or any combination thereof. Less commonly, asymptomatic bile duct stones are discovered incidentally on noninvasive imaging for nonbiliary indications, during evaluation of symptomatic cholelithiasis or intraoperatively during cholecystectomy. Since the universal adoption of laparoscopic cholecystectomy as the primary method for treating cholelithiasis in the early 1990s, only a minority of surgeons has mastered the techniques required for laparoscopic trancystic or direct choledochal exploration to treat choledocholithiasis, and there has been some reluctance to convert to open bile duct exploration for this indication. Many will recall that this was often the case for many surgeons even during the era of open cholecystectomy. Since ERCP became the standard approach for acute presentations of choledocholithiasis in the 1980s and with the overall success of endoscopic bile duct clearance, the question of treating cholelithiasis surgically became a secondary issue. While there is evidence that elective and emergent clearance of the bile duct by ERCP1Escourrou J. Cordova J.A. Lazorthes F. Frexinos J. Ribet A. Early and late complications after endoscopic sphincterotomy for biliary lithiasis, with and without the gallbladder ’in situ’.Gut. 1984; 25: 598-602Google Scholar, 2Tanaka M. Ikeda S. Yoshimoto H. Matsumoto S. The long-term fate of the gallbladder after endoscopic sphincterotomy.Am J Surg. 1987; 154: 505-509Google Scholar, 3Davidson B.R. Neoptolemos J.P. Carr-Locke D.L. Endoscopic sphincterotomy for common bile duct calculi in patients with gallbladder in situ considered unfit for surgery.Gut. 1988; 29: 114-120Google Scholar, 4Siegel J.H. Safrany L. Ben-Zvi J.S. Pullano W.E. Cooperman A. Stenzel M. Ramsey W.H. Duodenoscopic sphincterotomy in patients with gallbladders in situ reports of a series of 1272 patients.Am J Gastroenterol. 1988; 83: 1255-1258Google Scholar, 5Hill J. Martin F. Tweeddle D.E.F. Risk of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.Br J Surg. 1991; 78: 554-557Google Scholar, 6Neoptolemos J.P. Carr-Locke D.L. Fossard D.P. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.Br Med J. 1987; 294: 470-474Google Scholar, 7Stiegmann G.V. Goff J.S. Mansour A. Pearlman N. Reveille R.M. Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.Am J Surg. 1992; 163: 227-230Google Scholar, 8Hammarstrom L.E. Holmin T. Stridbeck H. Ihse I. Long-term follow-up of a prospective randomised study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.Br J Surg. 1995; 82: 1516-1521Google Scholar, 9Targarona E.M. Ayuso R.M. Bordas J.M. Ros E. Pros I. Martinez J. Teres J. Trias M. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients.Lancet. 1996; 347: 926-929Abstract Google Scholar had advantages over open bile duct exploration (usually combined with open cholecystectomy) the comparison of ERCP therapy with laparoscopic bile duct clearance is much more equivalent for most stones in the elective setting.10Cuschieri A. Lezoche E. Morino M. Croce E. Lacey A. Toouli J. Faggioni A. Ribeiro V.M. Jakimowicz J. Visa J. Hanna G.B. EAES multicenter prospective randomised trial comparing two-stage versus single-stage management of patients with gallstone disease and ductal calculi.Surg Endosc. 1999; 13: 952-957Google Scholar, 11Boerma D. Rauws E.A. Keulemans Y. Janssen I. Bolweck C.J. Timmer R. Boerma E.J. Obertop H. Huibregtse K. Gouma D.J. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones a randomised trial.Lancet. 2002; 360: 761-765Abstract Full Text Full Text PDF Scopus (251) Google Scholar Unfortunately, this surgical option is not always available and the evidence is therefore tempered by local expertise. Following endoscopic bile duct clearance, the decision to leave the gallbladder in situ and follow the patient expectantly [option (5) above] compared with routine laparoscopic cholecystectomy has been re-examined in the study reported in this issue by Lau et al in an exclusively Chinese population over the age of 60 years treated at the Prince of Wales Hospital, Chinese University of Hong Kong.12Lau J.Y.W. Leow C.-K. Fung T.M.K. Suen B.-Y. Yu L.-M. Lai P.B.S. Lam Y.-H. Ng E.K.W. Lau W.Y. Chung S.S.C. Sung J.J.Y. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients.Gastroenterology. 2006; 130: 96-103Google Scholar This study calls into question data from the past 2 decades which have helped shape endoscopic and surgical practice in certain patients considered high risk for cholecystectomy and it is timely to re-evaluate this algorithm. In the 1980s, the interpretation of several retrospective and fewer prospective series from respected endoscopy centers advocated in favor of a conservative strategy after ERCP bile duct clearance with gallbladder left in situ for patients considered at higher risk for open cholecystectomy.1Escourrou J. Cordova J.A. Lazorthes F. Frexinos J. Ribet A. Early and late complications after endoscopic sphincterotomy for biliary lithiasis, with and without the gallbladder ’in situ’.Gut. 1984; 25: 598-602Google Scholar, 2Tanaka M. Ikeda S. Yoshimoto H. Matsumoto S. The long-term fate of the gallbladder after endoscopic sphincterotomy.Am J Surg. 1987; 154: 505-509Google Scholar, 3Davidson B.R. Neoptolemos J.P. Carr-Locke D.L. Endoscopic sphincterotomy for common bile duct calculi in patients with gallbladder in situ considered unfit for surgery.Gut. 1988; 29: 114-120Google Scholar, 4Siegel J.H. Safrany L. Ben-Zvi J.S. Pullano W.E. Cooperman A. Stenzel M. Ramsey W.H. Duodenoscopic sphincterotomy in patients with gallbladders in situ reports of a series of 1272 patients.Am J Gastroenterol. 1988; 83: 1255-1258Google Scholar, 5Hill J. Martin F. Tweeddle D.E.F. Risk of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.Br J Surg. 1991; 78: 554-557Google Scholar, 6Neoptolemos J.P. Carr-Locke D.L. Fossard D.P. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.Br Med J. 1987; 294: 470-474Google Scholar, 7Stiegmann G.V. Goff J.S. Mansour A. Pearlman N. Reveille R.M. Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.Am J Surg. 1992; 163: 227-230Google Scholar Overall a 10% incidence of biliary events (pain, cholecystitis, empyema of the gallbladder, choledocholithiasis, cholangitis, liver abscess) over 10 years following treatment was often quoted to patients and this was considered acceptable in these mostly elderly populations. Subsequently, however, randomized studies demonstrated a much higher incidence of biliary events in those patients not undergoing post-ERCP open cholecystectomy of up to 28%.8Hammarstrom L.E. Holmin T. Stridbeck H. Ihse I. Long-term follow-up of a prospective randomised study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.Br J Surg. 1995; 82: 1516-1521Google Scholar, 9Targarona E.M. Ayuso R.M. Bordas J.M. Ros E. Pros I. Martinez J. Teres J. Trias M. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients.Lancet. 1996; 347: 926-929Abstract Google Scholar The equation, however, has changed again in the laparoscopic era with different risk stratification and the desire by patients and clinicians to manage gallstone disease in as minimally invasive a manner as possible. It is a straightforward decision to treat the patient with symptomatic cholelithiasis or an obvious gallbladder complication, such as cholecystitis, perforation or empyema, after successful bile duct therapy but the decision to treat cholelithiasis that is essentially asymptomatic after successful endoscopic bile duct clearance therefore depends on the risk of laparoscopic cholecystectomy balanced against the risk of biliary events during conservative management.10Cuschieri A. Lezoche E. Morino M. Croce E. Lacey A. Toouli J. Faggioni A. Ribeiro V.M. Jakimowicz J. Visa J. Hanna G.B. EAES multicenter prospective randomised trial comparing two-stage versus single-stage management of patients with gallstone disease and ductal calculi.Surg Endosc. 1999; 13: 952-957Google Scholar, 11Boerma D. Rauws E.A. Keulemans Y. Janssen I. Bolweck C.J. Timmer R. Boerma E.J. Obertop H. Huibregtse K. Gouma D.J. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones a randomised trial.Lancet. 2002; 360: 761-765Abstract Full Text Full Text PDF Scopus (251) Google Scholar It seems clear that the data of the past no longer apply at least to modern practice in Chinese patients over the age of 60 years in Hong Kong based on the Lau study.12Lau J.Y.W. Leow C.-K. Fung T.M.K. Suen B.-Y. Yu L.-M. Lai P.B.S. Lam Y.-H. Ng E.K.W. Lau W.Y. Chung S.S.C. Sung J.J.Y. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients.Gastroenterology. 2006; 130: 96-103Google Scholar They report a 7% occurrence of biliary events (83% cholangitis, 13% pain) after endoscopic bile duct clearance and laparoscopic cholecystectomy in contrast to 24% (67% cholangitis or jaundice, 24% cholecystitis, and 9% pain) after endoscopic duct clearance and gallbladder in situ. Although their patient recruitment was not consecutive and the very high surgical-risk patients were excluded, these observations are valuable. The only other similar prospective randomized trial came from the Netherlands11Boerma D. Rauws E.A. Keulemans Y. Janssen I. Bolweck C.J. Timmer R. Boerma E.J. Obertop H. Huibregtse K. Gouma D.J. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile duct stones a randomised trial.Lancet. 2002; 360: 761-765Abstract Full Text Full Text PDF Scopus (251) Google Scholar where a 47% incidence of biliary events was seen in the expectant gallbladder in situ group compared with none in the group undergoing cholecystectomy. Unlike this Dutch report and older series from the West, however, 70% of the biliary events in the Lau study12Lau J.Y.W. Leow C.-K. Fung T.M.K. Suen B.-Y. Yu L.-M. Lai P.B.S. Lam Y.-H. Ng E.K.W. Lau W.Y. Chung S.S.C. Sung J.J.Y. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients.Gastroenterology. 2006; 130: 96-103Google Scholar were related to the bile duct rather than the gallbladder, and this may imply a fundamental difference in disease behavior between East and West with a higher incidence of primary duct stones compared with the West. This could be used as an argument in favor of continued endoscopic management, which is, of course necessary, but the incidence of biliary events even without cholangitis is still noticeably higher in the gallbladder in situ group. In keeping with all other studies of following patients with gallbladder in situ after endoscopic sphincterotomy,1Escourrou J. Cordova J.A. Lazorthes F. Frexinos J. Ribet A. Early and late complications after endoscopic sphincterotomy for biliary lithiasis, with and without the gallbladder ’in situ’.Gut. 1984; 25: 598-602Google Scholar, 2Tanaka M. Ikeda S. Yoshimoto H. Matsumoto S. The long-term fate of the gallbladder after endoscopic sphincterotomy.Am J Surg. 1987; 154: 505-509Google Scholar, 3Davidson B.R. Neoptolemos J.P. Carr-Locke D.L. Endoscopic sphincterotomy for common bile duct calculi in patients with gallbladder in situ considered unfit for surgery.Gut. 1988; 29: 114-120Google Scholar, 4Siegel J.H. Safrany L. Ben-Zvi J.S. Pullano W.E. Cooperman A. Stenzel M. Ramsey W.H. Duodenoscopic sphincterotomy in patients with gallbladders in situ reports of a series of 1272 patients.Am J Gastroenterol. 1988; 83: 1255-1258Google Scholar, 5Hill J. Martin F. Tweeddle D.E.F. Risk of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.Br J Surg. 1991; 78: 554-557Google Scholar, 6Neoptolemos J.P. Carr-Locke D.L. Fossard D.P. Prospective randomized study of preoperative endoscopic sphincterotomy versus surgery alone for common bile duct stones.Br Med J. 1987; 294: 470-474Google Scholar, 7Stiegmann G.V. Goff J.S. Mansour A. Pearlman N. Reveille R.M. Precholecystectomy endoscopic cholangiography and stone removal is not superior to cholecystectomy, cholangiography, and common duct exploration.Am J Surg. 1992; 163: 227-230Google Scholar, 8Hammarstrom L.E. Holmin T. Stridbeck H. Ihse I. Long-term follow-up of a prospective randomised study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ.Br J Surg. 1995; 82: 1516-1521Google Scholar, 9Targarona E.M. Ayuso R.M. Bordas J.M. Ros E. Pros I. Martinez J. Teres J. Trias M. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients.Lancet. 1996; 347: 926-929Abstract Google Scholar nearly all of the cholecystitis occurred within the first year of follow-up suggesting that early cholecystectomy is logical. There is also an implication that later cholecystectomy is more difficult with a higher open conversion rate. This study, like all others that have examined it, showed no case of gallstone pancreatitis during follow-up after sphincterotomy. How then do we interpret these new data in the setting of current clinical practice in the East and West and with the experience of what has gone before? Where the expertise is available, elective management of cholelithiasis and choledocholithiasis by the laparoscopic approach should be offered. The role for ERCP in the management of acute calculous bile duct disease remains central and optimal. The majority of patients after successful endoscopic bile duct clearance should undergo laparoscopic cholecystectomy as early as possible to reduce the risk of a further biliary event or treat cholecystitis if already present.13Misra M. Schiff J. Rendon G. Rothschild J. Schwaitzberg S. Laparoscopic cholecystectomy after the learning curve what should we expect?.Surg Endosc. 2005; 19: 1266-1271Google Scholar, 14Lau H. Brooks D.C. Contemporary outcomes of ambulatory laparoscopic cholecystectomy in a major teaching hospital.World J Surg. 2002; 26: 1117-1121Google Scholar There will still be a small population of patients, however, considered at high risk for laparoscopic cholecystectomy and, in these, judicious conservative management of the in situ gallbladder is justifiable. Cholecystectomy or Gallbladder In Situ After Endoscopic Sphincterotomy and Bile Duct Stone Removal in Chinese PatientsGastroenterologyVol. 130Issue 1PreviewBackground & Aims: In patients with stones in their bile ducts and gallbladders, cholecystectomy is generally recommended after endoscopic sphincterotomy and clearance of bile duct stones. However, only approximately 10% of patients with gallbladders left in situ will return with further biliary complications. Expectant management is alternately advocated. In this study, we compared the treatment strategies of laparoscopic cholecystectomy and gallbladders left in situ.Methods: We randomized patients (>60 years of age) after endoscopic sphincterotomy and clearance of their bile duct stones to receive early laparoscopic cholecystectomy or expectant management. Full-Text PDF
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