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

Abstract

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.

Delay for cholecystectomy after common bile duct clearance with ERCP is just running after recurrent biliary event

“…In addition, reviews showed that RBE is definitively lower if cholecystectomy is carried out early vs delayed (2–10% vs 24–47%) [ 13 , 15 , 29 – 31 ]. While a better reduction in the risk of RBE is achieved the sooner cholecystectomy is carried out [ 12 , 42 , 52 ], the definition of “early” cholecystectomy after endoscopic treatment of choledocholithiasis remains variable [ 1 , 28 , 53 ]. This is reflected in guidelines recommending early cholecystectomy after periods varying from 24 h to 4 weeks [ 2 , 5 – 7 , 12 , 18 , 20 , 22 , 32 – 41 ].…”

“…Operative time may represent a surrogate of the difficulty of operation [ 53 ]. Operative time is higher after a previous ERCP [ 55 ], in emergency setting [ 28 ] and increases according to the number of episodes of cholecystitis [ 57 ]. Although the goal of this study was not to evaluate the relationship between cholecystitis and ERCP, its high incidence deserves to be considered as a contributing risk in the difficulty of delayed operation.…”

“…Cholecystectomy is associated with diminished recurrence of cholangitis [ 9 , 21 – 23 ], pancreatitis [ 24 – 27 ], or any biliary events after clearance of CBD [ 7 , 16 , 18 , 28 – 32 ]. Guidelines thus recommend cholecystectomy early after common bile duct clearance but for varying time periods from 24 h to 4 weeks [ 2 , 5 – 7 , 12 , 18 , 20 , 22 , 32 – 41 ].…”

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

“…It has been reported that delayed LC results in more morbidity and recurrent biliary symptoms ( 12 ). On the other hand, early LC can reduce re-admissions with gallstone-related symptoms and is not associated with worse surgical outcomes ( 8 ). Hence, early LC after ERCP in the same admission was adopted in our center.…”

“…However, the suitable interval time from ERCP to LC is still controversial and varies from hours to more than 6 weeks (7)(8)(9)(10)(11)(12)(13)(14)(15)(16)(17). It has been reported that delayed LC results in more morbidity and recurrent biliary symptoms (12).…”