Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high-risk surgical patients: a decision analysis.
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.
Siddiqui
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AA
Division of Gastroenterology and Hepatology, Thomas Jefferson University Hospital, Philadelphia, PA, USA. ali.siddiqui@utsouthwestern.edu
Mitroo
P
P
Kowalski
T
T
Loren
D
D
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