Endoscopic sphincterotomy with or without cholecystectomy for choledocholithiasis in high-risk surgical patients: a decision analysis


Dr A. A. Siddiqui, University of Texas Southwestern Medical Center, 4500 S. Lancaster Road (111B1), Dallas, TX 75216, USA. E-mail: ali.siddiqui@utsouthwestern.edu


Background  Laparoscopic cholecystectomy (LC) is recommended for patients with choledocholithiasis after ERCP with sphincterotomy (ES) and stone extraction.

Aim  We designed a decision model to address whether ES alone versus ES followed by LC (ES + LC) is the optimal treatment in high-risk patients with choledocholithiasis.

Methods  Our cohort were patients with obstructive jaundice who have undergone an ES with biliary clearance. Recurrent biliary complications over a 2-year period stratified by gallbladder status (in/out) and age-stratified surgical complication rates were obtained from the literature. Failure of therapy was defined as either recurrent symptoms or death attributed to biliary complications.

Results  For age 70–79 years, ES failed in 15% whereas ES + LC failed in 17% of cases. Mortality in the EC + LC group was 3.4 times that of the ES alone cohort. For age 80+ years, ES was dominant with an incremental success rate of 8%. Mortality in the ES + LC was 7.6 times that of ES. For age <70, ES + LC was the dominant strategy with an incremental success rate 5%. Sensitivity analysis in the groups confirmed our conclusions.

Conclusions  Management of choledocholithiasis by ES and stone clearance, but without cholecystectomy, should be considered for patients aged 70+. For low-risk patients, ES + LC should be performed to prevent recurrent biliary complications.