title: Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high-risk surgical patients: a decision analysis.
abstract: BACKGROUND
  Laparoscopic cholecystectomy (LC) is recommended for patients with choledocholithiasis after ERCP with sphincterotomy (ES) and stone extraction.
  
  
  OBJECTIVE
  We designed a decision model to address whether ES alone versus ES followed by LC (ES + LC) is the optimal treatment in high-risk patients with choledocholithiasis.
  
  
  METHODS
  Our cohort were patients with obstructive jaundice who have undergone an ES with biliary clearance. Recurrent biliary complications over a 2-year period stratified by gallbladder status (in/out) and age-stratified surgical complication rates were obtained from the literature. Failure of therapy was defined as either recurrent symptoms or death attributed to biliary complications.
  
  
  RESULTS
  For age 70-79 years, ES failed in 15% whereas ES + LC failed in 17% of cases. Mortality in the EC + LC group was 3.4 times that of the ES alone cohort. For age 80+ years, ES was dominant with an incremental success rate of 8%. Mortality in the ES + LC was 7.6 times that of ES. For age <70, ES + LC was the dominant strategy with an incremental success rate 5%. Sensitivity analysis in the groups confirmed our conclusions.
  
  
  CONCLUSIONS
  Management of choledocholithiasis by ES and stone clearance, but without cholecystectomy, should be considered for patients aged 70+. For low-risk patients, ES + LC should be performed to prevent recurrent biliary complications.
authors.affiliation: Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA. ali.siddiqui@utsouthwestern.edu
authors.forename: A A
authors.initials: AA
authors.lastname: Siddiqui
authors.forename: P
authors.initials: P
authors.lastname: Mitroo
authors.forename: T
authors.initials: T
authors.lastname: Kowalski
authors.forename: D
authors.initials: D
authors.lastname: Loren
mesh_terms: D000368:Aged; D000369:Aged, 80 and over; D002763:Cholecystectomy / Q000379:methods*; D042883:Choledocholithiasis / Q000601:surgery*; D015331:Cohort Studies; D003661:Decision Support Techniques; D006801:Humans; D012307:Risk Factors; D016717:Sphincterotomy, Endoscopic / Q000379:methods*; D015996:Survival Rate; D016896:Treatment Outcome