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Intervention Review

Surgical versus endoscopic treatment of bile duct stones

  1. David J Martin1,*,
  2. David Vernon2,
  3. James Toouli3

Editorial Group: Cochrane Hepato-Biliary Group

Published Online: 19 APR 2006

Assessed as up-to-date: 20 FEB 2006

DOI: 10.1002/14651858.CD003327.pub2


How to Cite

Martin DJ, Vernon D, Toouli J. Surgical versus endoscopic treatment of bile duct stones. Cochrane Database of Systematic Reviews 2006, Issue 2. Art. No.: CD003327. DOI: 10.1002/14651858.CD003327.pub2.

Author Information

  1. 1

    Sydney, NSW Australia, Australia

  2. 2

    Rotorua Hospital, Dept. of Surgery, Rotorua, New Zealand

  3. 3

    Flinders Medical Centre, Dept of General and Digestive Surgery, Adelaide, Australia

*David J Martin, 49 Hastings Parade, North Bondi, Sydney, NSW Australia, 2026, Australia. davidmartin72@hotmail.com. davidmartin72@hotmail.com.

Publication History

  1. Publication Status: Edited (no change to conclusions)
  2. Published Online: 19 APR 2006

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Abstract

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Background

10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery.

Objectives

To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy.

Search methods

We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005.

Selection criteria

The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up.

Data collection and analysis

Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required.

Main results

Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis.

Authors' conclusions

In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.

 

Plain language summary

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

Pre- or post-operative endoscopic retrograde cholangiopancreatography for bile duct clearance in patients undergoing cholecystectomy for gallstones offers no apparent advantage over surgical exploration

Between 10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct stones. Treatment options for these stones include pre- or post-operative endoscopy (endoscopic retrograde cholangiopancreatography), open surgery, or laparoscopic bile duct exploration. In the era of open cholecystectomy, open bile duct surgery was significantly superior to endoscopic retrograde cholangiopancreatography in achieving common bile duct stone clearance. A trend towards decreased mortality was also surprisingly seen in the surgical arm. Laparoscopic cholecystectomy with simultaneous laparoscopic bile duct exploration seem to be as safe and as efficient as endoscopic retrograde cholangiopancreatography, and avoid an extra procedure.

 

摘要

  1. Top of page
  2. Abstract
  3. Plain language summary
  4. 摘要

背景

比較以外科和內視鏡治療膽管結石

有10%至18%因膽結石而接受膽囊切除術的病患有膽管結石。治療選擇包括於術前或術後進行內視鏡逆行性膽胰管攝影術(ERCP),開腹手術或內視鏡手術

目標

系統性回顧對已經切除膽囊的患者,以下面四種治療方式處理其膽管結石:(1)ERCP比上開腹膽管清除手術 (2)術前ERCP比上內視鏡手術膽管清除手術 (3)術後ERCP比上內視鏡膽管清除手術 (4)ERCP比上內視鏡膽管清除手術

搜尋策略

系統性搜尋2005年11月前的主要相關電子資料庫,相關論文的文獻,相關次專科的學會摘要

選擇標準

由病患治療分配代碼產生過程,對治療盲性的保護,盲性和後續追蹤這些方面,評估納入試驗的品質

資料收集與分析

發表或未發表的資料,用12個事先選定的結果變項進行固定和隨機效益模式統合分析.探討異質性並在需要的地方進行敏感度和次族群分析

主要結論

13試驗,隨機分配了1351位病患.八個試驗(n = 760)比較ERCP與開腹清除手術,3個 (n = 425)比較術前ERCP 和內視鏡膽管清除手術,2個比較(n = 166)術後ERCP和內視鏡膽管清除手術,還有2個試驗比較.沒有試驗比較膽囊完整病患的ERCP 和內視鏡膽管清除手術.這10個試驗的3個變項中,最少有兩個其研究方法是夠好的. 在三組比較中, ERCP組的每人總手術數(包含治療併發症的手術)顯著增加,其加權平均差分別為0.62 (95% CI 0.15 – 1.09), 0.96 (95% CI 0.96 – 0.96),和1.09 (95% CI 0.93 1.24). 比起用開腹手術清除膽管結石, ERCP 較不成功(Peto OR 2.89, 95% CI 1.81 – 4.61),且傾向有較高死亡率 (風險差為1%, 95% CI −1% – 4%). 術前(Peto OR 1.00, CI 0.53 – 1.80) 和術後(OR 2.27, 95% CI 0.37 – 13.9)內視鏡清除膽管結石兩者效果相當,發病率和死亡率都沒有顯著差異. 內視鏡手術試驗都顯示手術組住院期間較短.沒有足夠資料進行成本分析/

作者結論

在開腹膽囊切除術的時代,切開膽管的手術比ERCP好,清除膽管結石效果較佳.在內視鏡的年代,資料快要能排除內視鏡與ERCP對清除膽管結石效果有差異.使用ERCP增加每病人手術數

翻譯人

本摘要由成功大學附設醫院尹子真翻譯。

此翻譯計畫由臺灣國家衛生研究院(National Health Research Institutes, Taiwan)統籌。

總結

術前或術後進行內視鏡逆行性膽胰管攝影術對膽囊切除術病患的膽管結石清潔效果沒有顯著優於手術.有10%至18%因膽結石而接受膽囊切除術的病患有膽管結石。治療選擇包括於術前或術後進行內視鏡逆行性膽胰管攝影術(ERCP),開腹手術或內視鏡手術.在開腹膽囊切除術的時代,切開膽管的手術比ERCP好,清除膽管結石效果較佳.手術組也意外的發現死亡率較低.腹腔鏡膽囊切除術併行膽管檢查和ERCP同樣安全及有效,也可避免額外手術