title: Initial cholecystectomy vs sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration: a randomized clinical trial.
abstract: OBJECTIVE
  The optimal management of treatment for patients at intermediate risk of a common duct stone (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) is a matter of debate. Many stones migrate spontaneously into the duodenum, making preoperative common duct investigations unnecessary.
  
  
  OBJECTIVE
  To compare strategies of cholecystectomy first vs a sequential endoscopic common duct assessment and cholecystectomy for the management of patients with an intermediate risk of a common duct stone. The main objective was to reduce the length of stay and the secondary objectives were to reduce the number of common duct investigations, morbidity, and costs.
  
  
  METHODS
  Interventional, randomized clinical trial with 2 parallel groups performed between June 2011 and February 2013, with a patient follow-up of 6 months. The trial comprised a random sample of 100 adult patients admitted to Geneva University Hospital, Geneva, Switzerland, for acute gallstone-related conditions with an intermediate risk of a common duct stone. Fifty patients were randomized to each group.
  
  
  METHODS
  Cholecystectomy first with intraoperative cholangiogram for the study group and endoscopic common duct assessment and clearance followed by cholecystectomy for the control group.
  
  
  METHODS
  Length of initial hospital stay (primary end point), number of common duct investigations and morbidity and mortality within 6 months after initial admission, and quality of life at 1 and 6 months after discharge (EQ-5D-5L [EuroQol Group, 5-level] questionnaire).
  
  
  RESULTS
  Patients who underwent cholecystectomy as a first step had a significantly shorter length of hospital stay (median, 5 days [interquartile range {IQR}, 1-8] vs median, 8 days [IQR, 6-12]; P < .001), with fewer common duct investigations (25 vs 71; P < .001), no significant difference in morbidity or quality of life.
  
  
  CONCLUSIONS
  Among patients at intermediate risk of a common duct stone, initial cholecystectomy compared with sequential common duct endoscopy assessment and subsequent surgery resulted in a shorter length of stay without increased morbidity. If these findings are confirmed, initial cholecystectomy with intraoperative cholangiogram may be a preferred approach.
  
  
  BACKGROUND
  Clinicaltrials.gov Identifier: NCT01492790.
authors.affiliation: Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland2Division of Transplant Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland3He.
authors.forename: Pouya
authors.initials: P
authors.lastname: Iranmanesh
authors.affiliation: Hepato-Pancreato-Biliary Centre, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland4Division of Gastroenterology and Hepatology, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerlan.
authors.forename: Jean-Louis
authors.initials: JL
authors.lastname: Frossard
authors.affiliation: Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland2Division of Transplant Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland.
authors.forename: Béatrice
authors.initials: B
authors.lastname: Mugnier-Konrad
authors.affiliation: Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland2Division of Transplant Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland3He.
authors.forename: Philippe
authors.initials: P
authors.lastname: Morel
authors.affiliation: Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland2Division of Transplant Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland3He.
authors.forename: Pietro
authors.initials: P
authors.lastname: Majno
authors.affiliation: Hepato-Pancreato-Biliary Centre, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland4Division of Gastroenterology and Hepatology, Department of Medical Specialties, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerlan.
authors.forename: Thai
authors.initials: T
authors.lastname: Nguyen-Tang
authors.affiliation: Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland2Division of Transplant Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland3He.
authors.forename: Thierry
authors.initials: T
authors.lastname: Berney
authors.affiliation: Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland2Division of Transplant Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland3He.
authors.forename: Gilles
authors.initials: G
authors.lastname: Mentha
authors.affiliation: Division of Digestive Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland2Division of Transplant Surgery, Department of Surgery, Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland3He.
authors.forename: Christian
authors.initials: C
authors.lastname: Toso
mesh_terms: D000328:Adult; D002758:Cholangiography; D017081:Cholecystectomy, Laparoscopic; D042883:Choledocholithiasis / Q000000981:diagnostic imaging / Q000601:surgery*; D003135:Common Bile Duct / Q000000981:diagnostic imaging / Q000473:pathology; D016099:Endoscopy, Gastrointestinal; D005260:Female; D006801:Humans; D007432:Intraoperative Period; D007902:Length of Stay; D008297:Male; D008875:Middle Aged; D011788:Quality of Life; D012306:Risk