Gastroenterology

Gastroenterology

Volume 138, Issue 7, June 2010, Pages 2315-2320
Gastroenterology

Clinical Advances in Liver, Pancreas, and Biliary Tract
Early Laparoscopic Cholecystectomy Improves Outcomes After Endoscopic Sphincterotomy for Choledochocystolithiasis

https://doi.org/10.1053/j.gastro.2010.02.052Get rights and content

Background & Aims

Patients with choledochocystolithiasis generally undergo endoscopic sphincterotomy (ES) followed by laparoscopic cholecystectomy (LC). However, many patients receive this surgery 6–8 weeks after ES. There is a high conversion rate of elective LC after ES, and patients can develop recurrent biliary events during the waiting period. We investigated whether the timing of surgery influences outcome.

Methods

We performed a randomized trial of patients with choledochocystolithiasis who underwent successful ES. Patients were randomly assigned to groups that received early LC (within 72 hours after ES, n = 49) or delayed LC (after 6–8 weeks, n = 47), based on an expected difference in conversion rate of 25% vs 5%, respectively. Conversion rate, biliary events during follow-up, duration and difficulty of surgeries, postoperative morbidity, and hospital stay were scored. Intention-to-treat analyses were performed.

Results

Groups were comparable in age, sex, and comorbidity. There was no difference between groups in conversion rate (4.3% in early vs 8.7% in delayed group) nor were there differences in operating times and/or difficulties or hospital stays. During the waiting period for LC, 17 patients in the delayed group (36.2%) developed recurrent biliary events compared with 1 patient in the early group (P < .001).

Conclusions

In a randomized trial to evaluate timing of LC after ES, recurrent biliary events occurred in 36.2% of patients whose LC was delayed for 6–8 weeks. Early LC (within 72 hours) appears to be safe and might prevent the majority of biliary events in this period following sphincterotomy.

Section snippets

Patients

Patients were recruited from the departments of surgery and gastroenterology of 5 large Dutch training hospitals. All patients of 18 years and older who underwent successful ES and stone extraction for choledocholithiasis and who had radiologically proven residual gallbladder stones were eligible for inclusion. Patients deemed not fit for surgery (American Society of Anaesthesiologists classes III and IV) and patients with biliary pancreatitis or acute cholecystitis were excluded from the

Results

Between June 2006 and October 2008, 96 patients were recruited. Forty-nine patients were allocated for ELC and 47 patients for DLC (Supplementary Figure 1). Because initial ES was often done in an acute setting outside regular working hours, information about patients eligible but not randomized was not complete. However, the patient characteristics of the study group concurred with those of earlier trials,5 thus we concluded that the randomized patients were representative of the general

Discussion

This is the first randomized controlled trial addressing the issue of timing of LC after ES in patients with combined choledochocystolithiasis. While waiting for LC in the DLC group, 36.2% of the patients suffered recurrent biliary symptoms, leading to emergency surgery in 23.5% of these patients. These events are avoided by early LC. The findings of this trial are in accordance with an earlier retrospective survey among our patients who underwent LC after ES. During a median waiting period of

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    Conflicts of interest The authors disclose no conflicts.

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    Copyright © 2010 AGA Institute. Published by Elsevier Inc. All rights reserved.