4632 Management of gallstone cholangitis in the era of laparoscopic cholecystectomy.

Abstract

Objective: To evaluate the treatment outcomes of gallstone cholangitis in the era of laparoscopic cholecystectomy (LC). Background: Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) followed by LC is a widely used approach for choledocholithiasis in the laparoscopic era, but the efficacy of such a combined approach specifically for gallstone cholangitis has not been documented. The long-term efficacy of ES without cholecystectomy for gallstone cholangitis is also unclear. Methods: Between 1995 and 1998, 184 patients (mean age 71, range 25-96 years) with gallstone cholangitis were managed with a protocol of ERCP and ES followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed. Patients considered high-risk for LC or who refused surgery after endoscopic management of cholangitis were followed for any recurrent biliary symptoms. Treatment outcomes and risk factors for recurrent biliary symptoms were analyzed. Results: ERCP was successful in 175 patients (95%). CBD stones were found in 147 patients, and endoscopic clearance was achieved in 132 (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After CBD stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and three underwent LCBDE with one conversion and no morbidity. There was no operative mortality. Seven-eight patients were managed conservatively after endoscopic clearance of CBD stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in-situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (p = 0.001). In both groups, the commonest recurrent symptom was cholangitis (n =5 and 14, respectively). Gallbladder in-situ (risk ratio 4.161, p = 0.011) and smallsize papillotomy (risk ratio 2.943, p = 0.037) were independent risk factors for recurrent biliary symptoms by multivariate analysis. Conclusions: ES for biliary drainage and stone removal, followed by interval LC, is an effective approach for gallstone cholangitis. ES alone is associated with a high incidence of recurrent cholangitis, especially if the size of papillotomy is small. LC should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk. Objective: To evaluate the treatment outcomes of gallstone cholangitis in the era of laparoscopic cholecystectomy (LC). Background: Endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) followed by LC is a widely used approach for choledocholithiasis in the laparoscopic era, but the efficacy of such a combined approach specifically for gallstone cholangitis has not been documented. The long-term efficacy of ES without cholecystectomy for gallstone cholangitis is also unclear. Methods: Between 1995 and 1998, 184 patients (mean age 71, range 25-96 years) with gallstone cholangitis were managed with a protocol of ERCP and ES followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed. Patients considered high-risk for LC or who refused surgery after endoscopic management of cholangitis were followed for any recurrent biliary symptoms. Treatment outcomes and risk factors for recurrent biliary symptoms were analyzed. Results: ERCP was successful in 175 patients (95%). CBD stones were found in 147 patients, and endoscopic clearance was achieved in 132 (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After CBD stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and three underwent LCBDE with one conversion and no morbidity. There was no operative mortality. Seven-eight patients were managed conservatively after endoscopic clearance of CBD stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in-situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (p = 0.001). In both groups, the commonest recurrent symptom was cholangitis (n =5 and 14, respectively). Gallbladder in-situ (risk ratio 4.161, p = 0.011) and smallsize papillotomy (risk ratio 2.943, p = 0.037) were independent risk factors for recurrent biliary symptoms by multivariate analysis. Conclusions: ES for biliary drainage and stone removal, followed by interval LC, is an effective approach for gallstone cholangitis. ES alone is associated with a high incidence of recurrent cholangitis, especially if the size of papillotomy is small. LC should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.