Endoscopic Management of Common Bile Duct Stones Leaving the Gallbladder in situ

Abstract

Background: Obstructive jaundice caused by stones is a common disorder, mostly managed by endoscopic sphincterotomy followed by cholecystectomy. The aim of this study was to evaluate whether or not clearance of the common bile duct alone is sufficient as treatment for patients with choledocholithiasis. Methods: A cohort with 447 patients with symptomatic cholecystocholedocholithiasis, undergoing endoscopic retrograde cholangiography (ERC) and if necessary sphincterotomy (ES). In 164 patients common bile duct stones were proven and treated endoscopically, without performing a subsequent cholecystectomy. All 164 patients were free of symptoms after the endoscopic intervention. This group of patients was compared with 78 patients who underwent cholecystectomy after endoscopic treatment of common bile duct stones. Patients were followed for 1–13 years after ERC and sphincterotomy results and complications were registered. Results: The ages of the 164 patients in the in situ group were significantly higher than in the cholecystectomy group and the ASA classification (American Society of Anesthesiologists) was significantly higher in the in situ patients. Mean follow-up was 70.9 months. Of the in situ patients 27 (16%) returned with biliary symptoms; 12 with common bile duct stones, three with cholangitis, and one with stenosis of Vater’s papilla. Eight patients returned with cholecystitis and 3 with symptomatic cholecystolithiasis. Thirteen patients underwent cholecystectomy and 11 were managed (also) endoscopically. Minor complications were 2 wound infections and 1 bleeding after cholecystectomy. Two patients (1%) died of abdominal sepsis due to cholecystitis. Of the patients who underwent cholecystectomy, 6 (7.6%) returned during follow-up. Three patients had common bile duct stones, 2 had cholangitis and 1 patient presented with papillostenosis. Three patients needed surgical common bile duct exploration and the other 3 were treated endoscopically. After reintervention, cardiopulmonary complications were observed in 1 patient. There was no related death. Conclusion: When common bile duct stones are treated successfully by endoscopic sphincterotomy and patients are free of symptoms, there is no need for routine prophylactic cholecystectomy.

Risk factors of acute cholecystitis after endoscopic common bile duct stone removal

“…Because two patients in whom acute cholecystitis developed also experienced CBD stone recurrence and there was no case of cholangitis or CBD stricture, the overall recurrence rate of biliary-related events during follow-up after endoscopic CBD stone removal was 28% (28/100), which is similar to the rates of 5-24% reported www.wjgnet.com recent prospective [7] and large scale cohort studies [9] produced contrary conclusions concerning prophylactic cholecystectomy vs the wait-and-see approach. Moreover, because no consensus has been reached, the decision as to whether to operate or not is made empirically on a case-by-case basis [8,13,[17][18][19] .…”

“…We believed that if the risk factors of acute cholecystitis in patients who receive an endoscopic CBD stone removal could be identified, we might be able to identify the indicators of prophylactic cholecystectomy, as has been mentioned by earlier investigators [13] . Some studies have compared the results of prophylactic cholecystectomy and non-surgical treatment [7,9,17] . However, as far as we know, few studies have addressed the risk factors of acute cholecystitis after endoscopic CBD stone removal in patients with GB in situ, and thus our report might be the first to focus on this subject.…”

“…Because gallstones may pass from the gallbladder (GB) into the CBD, calculous GB is considered to be one of the risk factors for the recurrence of bile duct stones after sphincterotomy [4,6] . Some studies have compared the results of the wait-andsee policy and prophylactic cholecystectomy to prevent biliary complications but arrived at contradictory results [7][8][9] . Thus, it still remains controversial as to whether subsequent laparoscopic cholecystectomy is indicated in patients with concurrent GB stones.…”

Endoscopic Sphincterotomy With or Without Cholecystectomy for Choledocholithiasis in High Risk Surgical Patients: A Decision Analysis

“…The findings in this study confirmed that endoscopic treatment alone in this group of patients was feasible treatment principle. Several other studies 1,[35][36][37] have further confirmed that octogenarians with common bile duct calculi do well with ES alone on long-term follow-up.…”

Endoprótesis biliar en el manejo transitorio de la coledocolitiasis

“…Aunque la principal indicación para el manejo endoscópico de la litiasis biliar sigue siendo la presencia de cálculos residuales o recidivantes, cada vez con mayor frecuencia se utiliza en pacientes con vesícula in situ, ya sea como paso preoperatorio o en casos seleccionados, como tratamiento definitivo 9,10 .…”