title: Cholecystocholedocholithiasis: a case-control study comparing the short- and long-term outcomes for a "laparoscopy-first" attitude with the outcome for sequential treatment (systematic endoscopic sphincterotomy followed by laparoscopic cholecystectomy).
abstract: BACKGROUND
  No unanimous consensus has been achieved regarding the ideal management of cholecystocholedocholithiasis. The treatment of gallbladder and common bile duct (CBD) stones may be achieved currently according to a two-step-protocol (endoscopic sphincterotomy associated with laparoscopic cholecystectomy) or by a one-step laparoscopic procedure, including exploration of the CBD and cholecystectomy. Endoscopic sphincterotomy is reported to have considerable morbidity/mortality and CBD stone recurrence rates, whereas laparoscopic CBD clearance is a demanding procedure, which to date has not spread beyond specialized environments.
  
  
  METHODS
  To evaluate our "laparoscopy first" (LF) approach for patients affected by gallbladder/CBD stones (laparoscopic exploration and intraoperative decision whether to proceed with laparoscopic CBD exploration or to postpone CBD stone treatment to a postoperative endoscopic retrograde cholangiopancreatography [ERCP]), we performed a retrospective, two-center case-control comparison of the postoperative outcome for 49 consecutive patients treated for gallbladder/CBD stones from January 2000 through December 2004. The results obtained with this LF approach were compared with those achieved with the traditional, "endoscopy-first" (EF) approach (ERCP plus endoscopic sphincterotomy, followed by laparoscopic cholecystectomy). The mean follow-up period was 6.4 years (range, 4-8 years).
  
  
  RESULTS
  No difference emerged concerning early and late complications, mortality, or laparotomies needed to accomplish cholecystectomy and CBD clearance. The postoperative hospital stay was shorter for the LF group. In the LF group, only 22 patients underwent choledochotomy (45%), and 15 patients underwent perioperative ERCP (30%). Conversions decreased with practice. After choledochotomy, an increasing number of patients underwent primary closure of the CBD (with no biliary drain), without complications.
  
  
  CONCLUSIONS
  An LF approach to gallbladder/CBD stones is safe and feasible. It may allow the majority of surgeons to avoid excessively difficult/dangerous surgical procedures as well as unnecessary ERCPs in most cases. A tendency toward a lower incidence of conversions and a rarer use of biliary drains may lead to an improved immediate outcome for patients undergoing an LF approach.
authors.affiliation: Service de Chirurgie Viscérale Digestive et Urologique, Hôpital Victor Dupouy, Argenteuil, France. renatocosti@hotmail.com
authors.forename: Renato
authors.initials: R
authors.lastname: Costi
authors.forename: Antonio
authors.initials: A
authors.lastname: Mazzeo
authors.forename: Francesco
authors.initials: F
authors.lastname: Tartamella
authors.forename: Christine
authors.initials: C
authors.lastname: Manceau
authors.forename: Bernard
authors.initials: B
authors.lastname: Vacher
authors.forename: Alain
authors.initials: A
authors.lastname: Valverde
mesh_terms: D016022:Case-Control Studies; D002760:Cholangiopancreatography, Endoscopic Retrograde; D017081:Cholecystectomy, Laparoscopic; D041761:Cholecystolithiasis / Q000601:surgery*; D042883:Choledocholithiasis / Q000601:surgery*; D003135:Common Bile Duct / Q000601:surgery; D005260:Female; D005500:Follow-Up Studies; D006801:Humans; D008297:Male; D008875:Middle Aged; D012189:Retrospective Studies; D016717:Sphincterotomy, Endoscopic; D013997:Time Factors; D016896:Treatment Outcome