Bile Duct Clearance and Cholecystectomy for Choledocholithiasis : Definitive Single-Stage Laparoscopic Cholecystectomy with Intra-Operative Endoscopic Retrograde Cholangiopancreatography (ERCP) versus Staged Procedures

• BACKGROUND: Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner.METHODS: Records were reviewed for all patients admitted between January 2015-December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intra-operative rendezvous ERCP at index admission (one-stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two-stage) at the Irish hospital. Clinical characteristics, post-procedural complications, and inpatient duration were compared between cohorts.RESULTS: Three hundred and fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222(62.2%) underwent a one-stage procedure in Sweden, while 135(37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and pre-operative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein = 136±137 vs. 95±102mg/L,p=0.024), had higher incidence of co-morbidities (age-adjusted Charlson Comorbidity Index ≥3:37.8% vs 20.0%,p=0.003), and overall were less fit for surgery (ASA ≥3: 11.7% vs. 3.7%,p < 0.001). Despite this, a significantly-shorter mean time to definitive treatment, i.e., cholecystectomy (3.1±2.5 vs. 40.3±127 days,p=0.017), without excess morbidity, was seen in the one-stage compared to the two-stage cohort. Patients in the one-stage cohort experienced shorter mean post-procedure length of stay(3.0±4.7 vs 5.0±4.6 days,p < 0.001) and total length of hospital stay(6.5±4.6 vs 9.0±7.3 days,p=0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p=0.004).CONCLUSION: Where appropriate expertise and logistics exist within developing models of Acute Care Surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest this strategy significantly shortens the time to definitive treatment, decreases total hospital stay without any excess in adverse outcomes.

Ämnesord

MEDICIN OCH HÄLSOVETENSKAP  -- Klinisk medicin -- Kirurgi (hsv//swe)

MEDICAL AND HEALTH SCIENCES  -- Clinical Medicine -- Surgery (hsv//eng)

Nyckelord

Choledocholithiasis

intraoperative ERCP

laparoscopic cholecystectomy

Publikations- och innehållstyp

ref (ämneskategori)

art (ämneskategori)