Cholecystectomy after endoscopic sphincterotomy in elderly: A dilemma
Cholecystectomy in geriatric age
Keywords:Sphincterotomy, Endoscopic, Cholecystectomy, Aged, Geriatrics
Background/Aim: Although cholecystectomy is recommended by many guidelines after endoscopic retrograde cholangiopancreatography (ERCP) for gallstones, the necessity of cholecystectomy in geriatric patients is a matter of debate. Here we compare the outcomes of new biliary events in cholecystectomized and non-cholecystectomized patients of geriatric age after ERCP for suspected choledocholithiasis.
Methods: Non-cholecystectomized patients who underwent ERCP for choledocholithiasis from 2015 to 2017 were included in this retrospective cohort study. Patients with other biliary pathologies, incomplete clearance of common bile duct stones, and those who could not be reached at follow-up were excluded from the study. Biliary events (cholecystitis, cholangitis, pancreatitis, re-ERCP) were evaluated by considering age groups in patients with and without cholecystectomy in their follow-up after sphincterotomy.
Results: A total of 284 patients were followed for an average of 69.77 (0.2) months. The cumulative incidence of biliary events in cholecystectomized patients was lower (16% vs. 21.5%; P < 0.001), and cholecystectomized patients had a longer time to the occurrence of events (mean 74.49 [0.27] months vs. 73.50 [0.33] months; P = 0.03). There was no significant difference in the frequency of biliary events between elderly patients with and without cholecystectomy (P = 0.81), and the cumulative incidence of biliary events in the in situ group was significantly lower than that in the geriatric group (17.5% vs 32.6%; P = 0.03)
Conclusion: Although cholecystectomy significantly reduces subsequent biliary complications in young patients, it does not provide a statistically significant benefit in geriatric patients. We believe that there may be no need for routine prophylactic cholecystectomy after endoscopic sphincterotomy in geriatric patients.
Pak M, Lindseth G. Risk factors for cholelithiasis. Gastroenterol Nurs. 2016;39(4):297–309. DOI: https://doi.org/10.1097/SGA.0000000000000235
Gutt C, Schläfer S, Lammert F. The treatment of gallstone disease. Dtsch Arztebl Int. 2020 Feb 28;117(9):148–58. DOI: https://doi.org/10.3238/arztebl.2020.0148
Vasil’ev IV, Selezneva EI, Dubtsova EA. [Biliary pancreatitis]. Exp Clin Gastroenterol. 2011;17(7):79–84.
Escourrou J, Cordova JA, Lazorthes F, Frexinos J, Ribet A. Early and late complications after endoscopic sphincterotomy for biliary lithiasis with and without the gallbladder “in situ.” Gut. 1984;25(6):598–602. DOI: https://doi.org/10.1136/gut.25.6.598
Tanaka M, Ikeda S, Yoshimoto H, Matsumoto S. The long-term fate of the gallbladder after endoscopic sphincterotomy. Complete follow-up study of 122 patients. Am J Surg. 1987;154(5):505–9. DOI: https://doi.org/10.1016/0002-9610(87)90265-0
Davidson BR, Neoptolemos JP, Carr-Locke DL. Endoscopic sphincterotomy for common bile duct calculi in patients with gall bladder in situ considered unfit for surgery. Gut. 1988;29(1):114–20. DOI: https://doi.org/10.1136/gut.29.1.114
Siegel JH, Safrany L, Ben‐Zvi JS, Pullano WE, Cooperman A, Stenzel M, et al. Duodenoscopic Sphincterotomy in Patients with Gallbladders in Situ: Report of a Series of 1272 Patients. Am J Gastroenterol. 1988;83(11):1255–8.
Lammert F, Acalovschi M, Ercolani G, van Erpecum KJ, Gurusamy KS, van Laarhoven CJ, et al. EASL Clinical Practice Guidelines on the prevention, diagnosis and treatment of gallstones. J Hepatol. 2016 Jul 1;65(1):146–81. DOI: https://doi.org/10.1016/j.jhep.2016.03.005
Gutt C, Jenssen C, Barreiros AP, Götze TO, Stokes CS, Jansen PL, et al. Updated S3-Guideline for Prophylaxis, Diagnosis and Treatment of Gallstones. German Society for Digestive and Metabolic Diseases (DGVS) and German Society for Surgery of the Alimentary Tract (DGAV): AWMF Registry 021/008. Vol. 56, Zeitschrift fur Gastroenterologie. Z Gastroenterol; 2018. p. 912–66.
Overby DW, Apelgren KN, Richardson W, Fanelli R. SAGES guidelines for the clinical application of laparoscopic biliary tract surgery. Vol. 24, Surgical Endoscopy. Surg Endosc; 2010. p. 2368–86. DOI: https://doi.org/10.1007/s00464-010-1268-7
Carr-Locke DL. Cholelithiasis plus choledocholithiasis: ERCP first, what next? Vol. 130, Gastroenterology. Elsevier; 2006. p. 270–2. DOI: https://doi.org/10.1053/j.gastro.2005.12.010
Murabayashi T, Kanno Y, Koshita S, Ogawa T, Kusunose H, Sakai T, et al. Long-term outcomes of endoscopic papillary large-balloon dilation for common bile duct stones. Intern Med. 2020;59(7):891–9. DOI: https://doi.org/10.2169/internalmedicine.3881-19
Sousa M, Pinho R, Proença L, Rodrigues J, Silva J, Gomes C, et al. Choledocholithiasis in elderly patients with gallbladder in situ - is ERCP sufficient? Scand J Gastroenterol. 2018 Nov 2;53(10–11):1388–92. DOI: https://doi.org/10.1080/00365521.2018.1524022
Lau JYW, Leow CK, Fung TMK, Suen BY, Yu LM, Lai PBS, et al. Cholecystectomy or gallbladder in situ after endoscopic sphincterotomy and bile duct stone removal in Chinese patients. Gastroenterology. 2006;130(1):96–103. DOI: https://doi.org/10.1053/j.gastro.2005.10.015
Russell JC, Walsh SJ, Reed-Fourquet L, Mattie A, Lynch J. Symptomatic cholelithiasis: A different disease in men? Ann Surg. 1998;227(2):195–200. DOI: https://doi.org/10.1097/00000658-199802000-00007
Lord AC, Hicks G, Pearce B, Tanno L, Pucher PH. Safety and outcomes of laparoscopic cholecystectomy in the extremely elderly: a systematic review and meta-analysis. Vol. 119, Acta Chirurgica Belgica. Acta Chir Belg; 2019. p. 349–56. DOI: https://doi.org/10.1080/00015458.2019.1658356
Yasui T, Takahata S, Kono H, Nagayoshi Y, Mori Y, Tsutsumi K, et al. Is cholecystectomy necessary after endoscopic treatment of bile duct stones in patients older than 80 years of age? J Gastroenterol. 2012 Jan;47(1):65–70. DOI: https://doi.org/10.1007/s00535-011-0461-3
Boytchev I, Pelletier G, Prat F, Choury AD, Fritsch J, Buffet C. [Late biliary complications after endoscopic sphincterotomy for common bile duct stones in patients older than 65 years of age with gallbladder in situ]. Gastroenterol Clin Biol. 2000 Nov;24(11):995–1000.
Nassar Y, Richter S. Management of complicated gallstones in the elderly: Comparing surgical and non-surgical treatment options. Gastroenterol Rep. 2019 Jun 1;7(3):205–11. DOI: https://doi.org/10.1093/gastro/goy046
Boerma D, Rauws EAJ, Keulemans YCA, Janssen IMC, Bolwerk CJM, Timmer R, et al. Wait-and-see policy or laparoscopic cholecystectomy after endoscopic sphincterotomy for bile-duct stones: A randomized trial. Lancet. 2002 Sep 7;360(9335):761–5. DOI: https://doi.org/10.1016/S0140-6736(02)09896-3
Schreurs WH, Vles WJ, Stuifbergen WHNM, Oostvogel HJM. Endoscopic management of common bile duct stones leaving the gallbladder in situ: A cohort study with long-term follow-up. Dig Surg. 2004;21(1):60–4. DOI: https://doi.org/10.1159/000075944
Lai KH, Lo GH, Lin CK, Hsu PI, Chan HH, Cheng JS, et al. Do patients with recurrent choledocholithiasis after endoscopic sphincterotomy benefit from regular follow-up? Gastrointest Endosc. 2002;55(4):523–6. DOI: https://doi.org/10.1067/mge.2002.122611
Sandblom G, Videhult P, Crona Guterstam Y, Svenner A, Sadr-Azodi O. Mortality after a cholecystectomy: A population-based study. HPB. 2015 Mar 1;17(3):239–43. DOI: https://doi.org/10.1111/hpb.12356
Scollay JM, Mullen R, McPhillips G, Thompson AM. Mortality associated with the treatment of gallstone disease: A 10-year contemporary national experience. World J Surg. 2011 Mar;35(3):643–7. DOI: https://doi.org/10.1007/s00268-010-0908-3
Khan MA, Khan Z, Tombazzi CR, Gadiparthi C, Lee W, Wilcox CM. Role of Cholecystectomy after Endoscopic Sphincterotomy in the Management of Choledocholithiasis in High-risk Patients A Systematic Review and Meta-Analysis. Vol. 52, Journal of Clinical Gastroenterology. J Clin Gastroenterol; 2018. p. 579–89. DOI: https://doi.org/10.1097/MCG.0000000000001076
Xu J, Yang C. Cholecystectomy outcomes after endoscopic sphincterotomy in patients with choledocholithiasis: A meta-analysis. BMC Gastroenterol. 2020 Jul 17;20(1). DOI: https://doi.org/10.1186/s12876-020-01376-y
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Copyright (c) 2022 Ahmed Ramiz Baykan , Serkan Cerrah , Levent Ogul , Ayetullah Temiz , Elmas Kasap
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