Long-Term Outcomes of Elderly Patients Managed Without Early Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography and Sphincterotomy for Choledocholithiasis

Abstract

BackgroundProphylactic cholecystectomy following endoscopic retrograde cholangiopancreatography with sphincterotomy (ERCP-S) remains the gold standard management of choledocholithiasis. Some clinicians propose ERCP-S alone as the definitive management in the elderly, given perioperative complication risks. This retrospective cohort study aimed to assess the long-term efficacy and safety of non-operative management of choledocholithiasis in adults aged ≥70. MethodologyA total of 252 patients aged ≥70 underwent ERCP from 2004 to 2014 at a single institution. The rates of cholecystectomy, ERCP, complications, and mortality were gathered. Data were linked to a provincial health database to capture follow-up visits to alternate hospitals. Predictors of operation, recurrence, and mortality were analyzed using multivariable regression. ResultsFollowing ERCP, of the 252 patients, 33 (13.1%) underwent prophylactic cholecystectomy within three months, while 219 (86.9%) were initially managed conservatively. Of the 219 patients, 147 (67.1%) experienced no further choledocholithiasis after conservative management, while 23 (10.5%) patients underwent cholecystectomy. The mean follow-up was 2.9 years. Delayed operative patients were younger (mean age: 77.56 vs. 82.90; p < 0.001) and had lower Charlson Comorbidity Index (CCI) (1.04 vs. 1.84; p = 0.030). When adjusted for age, CCI score, and sex, cholecystectomy was associated with increased survival, with an odds ratio of 0.48 (95% confidence interval = 0.26-0.90; p = 0.021). Perioperative complications occurred in 7/56 (12.5%) patients. ConclusionsRecurrent choledocholithiasis is common in elderly patients. Despite recurrent symptoms, these patients are unlikely to undergo cholecystectomy. Surgeons operate on patients with greater life expectancy and fewer comorbidities with high success despite advanced patient age. Future prospective studies should examine objective criteria for prophylactic cholecystectomy in this population, given purported safety and benefits.

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

“…In this retrospective study, all types of gallstone related events after ERCP and clearance of CBD are included. The 28.5% occurrence of RBE after endoscopic CBDS extraction in this series correlates with a previously reported incidence of 17% to 60% [ 4 , 12 , 15 , 19 , 22 , 25 , 29 , 31 , 42 , 43 ]. In two prospective randomized trials, after a wait-and-see policy, 24% [ 30 ] and 47% [ 29 ] of the patients presented with RBE, respectively.…”

“…Yet, index cholecystectomy after ERCP have been demonstrated to be secure, with fewer or at least no increased risk of complications [ 12 , 13 , 25 – 27 , 42 , 49 , 51 ], along with the prevention of RBE [ 3 , 7 , 16 , 20 , 21 , 29 – 31 , 43 , 44 , 49 – 51 ]. Age and comorbidity should not be an obstacle or a deterrent to proceed to early cholecystectomy or even at the index admission after the endoscopic removal of CBDS, except when risk is prohibitive [ 4 ].…”

“…Gallstone disease affects 7–15% of the adult population throughout the life [ 1 , 2 ]. Prevalence may reach 80% at the age of 90 [ 3 , 4 ]. Concomitant common bile duct stone (CBDS) occurs in 5–30% of the patients [ 2 , 5 – 7 ].…”

“…Endoscopic retrograde cholangiopancreatography (ERCP) is the mainstay of management for the removal of CBDS [ 11 , 13 ]. ERCP remains insufficient, since recurrence of CBDS occurs in up to 30% [ 4 , 14 ], and recurrence of any related biliary events (RBE) in up to 47% of the cases [ 15 , 16 ] despite clearance of the common bile duct (CBD). While ERCP fails to prevent further RBE [ 7 , 16 – 18 ], cholecystectomy does prevent the RBE in majority of the cases [ 15 , 17 , 19 , 20 ].…”

Ruptured Middle Colic Artery Aneurysm Presenting with Symptoms of Acute Cholecystitis: A Case Report and Literature Review

“…However, given the presence of gallstones on preoperative ultrasound, cholecystectomy at the index laparotomy could have been a reasonable option. The risk of recurrent gallstone-related disease, even in elderly patients with significant comorbidities, is important, 19 and cholecystectomy is typically recommended for symptomatic patients who can tolerate the procedure. 20 Furthermore, an interval cholecystectomy, if necessary, would likely be very challenging in this patient due to the resultant adhesions from her adjacent intra-abdominal hemorrhage and prior laparotomy.…”