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Do you need to take the Gallbladder out after bile duct clearance? |
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Management of the gallbladder after bile duct clearance
4 RCT’s have been published recently
Boerma D, Rauws EA, Keulemans YC, et al. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bileduct stones: a randomised trial. Lancet 2002;360:761-5.
• 120 patients aged 18 to 80 years with proved symptomatic common bile duct and concomitant gallbladder stones who underwent ES and bile duct clearance.
• Patients were randomized to:
LC within 6 weeks of endoscopic stone clearance
“wait and see” approach.
• Results
mean follow-up period of 30 months
• 47% of patients in the wait and see group had recurrent biliary symptoms compared with 2% in the LC group.
• 37% of the wait and see group needed cholecystectomy.
Targarona EM, Ayuso RM, Bordas JM, et al. Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients. Lancet 1996;347:926-9.
• randomized 98 elderly and other high-risk patients with symptoms likely caused by
bile duct stones
– ES alone
– open surgery
• Result
– mean follow-up of 17 months,
• biliary symptoms recurred in 20% of the ES group and 6% of the surgery group.
Hammarstrom LE, Holmin T, Stridbeck H, Ihse I. Long-term follow-up of a prospective randomized study of endoscopic versus surgical treatment of bile duct calculi in patients with gallbladder in situ. Br J Surg 1995;82:1516-21.
• randomized 83 patients with bile duct stones
– ES and stone removal
– open surgery (cholecystectomy and bile duct exploration
• Result
– after more than 5 years,
• 20% of the ES group underwent cholecystectomy because of recurrent biliary symptoms
• 2% of patients in the surgery group had recurrent symptoms from bile duct stones.
• During the follow-up period, nonbiliary mortality was significantly more common in the ES group
Panis Y, Suc B, Escat J. Surgery versus endoscopic sphincterotomy for choledocholithiasis: results of a prospective randomized study. Gastroenterology 1995;108:A431.
• randomized 206 patients with common bile duct stones
– endoscopic therapy alone
– surgery
• Result
– early surgery was required in 19% in the endoscopic group,
– only 2% of the surgical group needed reoperation.
Recommendation:
Patients with cholangitis should undergo elective Lap Chole after bile duct
clearance if they are fit for surgery (unless an open approach is known to be
required).
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