Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone

• Published in: Gastrointestinal endoscopy Vol. 85; no. 4; pp. 794 - 802
• Main Authors: Iranmanesh, Pouya, MD, Tobler, Olivier, MD, De Sousa, Sandra, MD, Frossard, Jean-Louis, MD, Morel, Philippe, MD, Toso, Christian, MD, PhD
• Format: Journal Article
• Language: English
• Published: United States Elsevier Inc 01.04.2017
• Subjects: Adult; Aged; Aged, 80 and over; Alanine Transaminase - blood; Alkaline Phosphatase - blood; Aspartate Aminotransferases - blood; Bilirubin - blood; Cholecystectomy, Laparoscopic - methods; Choledocholithiasis - blood; Choledocholithiasis - epidemiology; Choledocholithiasis - surgery; Endoscopy, Digestive System; Female; Gallstones - epidemiology; Gallstones - surgery; gamma-Glutamyltransferase - blood; Gastroenterology and Hepatology; Humans; Length of Stay; Lipase - blood; Male; Middle Aged; Prospective Studies; Risk Assessment; CBD; body mass index; Society of American Gastrointestinal and Endoscopic Surgeons; ASGE; liver function test; RUQ; right upper quadrant; common bile duct stone; SAGES; American Society for Gastrointestinal Endoscopy; intraoperative cholangiogram; LFT; IOC; BMI
• ISSN: 0016-5107; 1097-6779
• DOI: 10.1016/j.gie.2016.08.015

Background and Aims Initial cholecystectomy for patients at intermediate risk of common bile duct (CBD) stones (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) showed shorter length of stay and fewer CBD investigations without increased morbidity compared with sequential CBD endoscopic assessment and subsequent cholecystectomy in a randomized controlled trial. The objectives were to prospectively validate these results in daily clinical practice and discuss current guidelines. Methods Initial cholecystectomy has become the standard management strategy at Geneva University Hospitals since July 2013 for patients at intermediate risk of CBD stones admitted with acute gallstone-related conditions. Between July 2013 and December 2014, length of stay, number of CBD investigations, and number of adverse events were recorded for these patients and compared with the data of the patients in the randomized controlled trial. Results Data for 161 consecutive newly assessed patients at intermediate risk of CBD stones confirmed shorter length of stay (7.6 vs 9.8 days; P  < .001), fewer CBD investigations (0.8 vs 1.4 investigations per patient; P  < .001), and similar adverse event rates (5.6% vs 14%, P  = .14 including all adverse events; 3.1% vs 8%, P  = .22 including only grade ≥III adverse events, defined by endoscopic/surgical reintervention or intensive care unit admission) compared with the previously reported group of patients who underwent preoperative CBD investigations. Conclusions These data confirm that initial cholecystectomy results in a shorter length of stay without increased morbidity among patients at intermediate risk of CBD stones compared with sequential CBD assessment and subsequent cholecystectomy. This approach may change current guidelines.