Aspects on interventions in complicated gallstone disease

Abstract

Background: Laparoscopic cholecystectomy (LC) is the standard treatment for symptomatic gallstone disease. In 10-15% of these patients, common bile duct stones (CBDS) are encountered. These are managed commonly by endoscopic retrograde cholangiopancreatography (ERCP). Rendezvous (RV) intraoperative (IO) ERCP is performed during ongoing cholecystectomy when the cannulation of the bile duct is assisted by a guidewire. When RV ERCP cannot be performed in one session, the so-called RV postoperative (PO) ERCP may be performed.

Objectives: 1) To investigate the risk of post-ERCP pancreatitis (PEP) and stone clearance rate in RVIO ERCP for concomitant CBDS during cholecystectomy. 2) To study cholecystectomy rates in Sweden and correlate cholecystectomy rates with the corresponding rates of gallstone complications (GSC). 3) To compare RVIO ERCP with RVPO ERCP in terms of morbidity and stone clearance. 4) To study the risk of gallstone and cholecystectomy related complications if cholecystectomy is scheduled 6 weeks after the initial episode of mild gallstone pancreatitis.

Methods: 1) A single center retrospective study of all consecutive IO ERCP procedures between 2000 and 2009. 2) A nationwide registry-based study of all cholecystectomies between 1998 and 2013. Gallstone complications (pancreatitis and cholecystitis) were collected between 1998 and 2013 and indications for cholecystectomy between 2006 and 2013. The age and gender adjusted annual incidences per 100 000 inhabitants were calculated for the Swedish counties. 3) A nationwide registry-based study of all RV ERCP procedures performed for gallstone indications between 2008 and 2014. 4) A single center randomized controlled trial with two parallel arms. Between May 2009 and July 2017, sixty-six patients with mild gallstone pancreatitis were randomized to index cholecystectomy (IC, n=32) or scheduled cholecystectomy (SC, n=34).

Results: 1) 307 patients were managed by IO ERCP. When RV cannulation was successful (86%), the PEP risk was 0.4% compared with 14% when conventional cannulation technique was used (p < 0.001). Stone clearance was achieved in 88.3%. No mortality occurred within 90 days. 2) A total of 178 441 cholecystectomies were studied. The annual cholecystectomy rates varied widely between the Swedish counties, with a two-fold difference (median 156, range 100 – 207). There was no inverse correlation between the cholecystectomy and GSC rates. 3) A total of 1205 RVIO and 565 RVPO ERCP procedures were retrieved. The RVPO ERCP technique was associated with increased risk for PEP (6.4% vs. 3.2%, p=0.003) and postoperative infections (4.4% vs. 2.3%, p=0.028) compared with the RVIO ERCP. 4) Gallstone-related complications occurred in nine patients (5 patients with recurrent pancreatitis and 4 patients with biliary colic) in the SC group compared with one patient with pancreatitis in the IC group (26.4% vs. 3.1%, p=0.013). Cholecystectomy-related complications occurred in two patients in the SC group compared with one patient in the IC group (7.1% vs. 3.2%, p=0.6). Fewer patients were found to have CBDS in the SC group compared with the IC group (10.7% vs. 22.5%, p=0.3).

Conclusions: RVIO ERCP is feasible and has low risk of PEP. A high rate of cholecystectomy does not seem to protect from gallstone complications. RVIO ERCP is superior to RVPO, both in terms of PEP and postoperative infections. To minimize the risk for additional gallstone-related complications, patients with mild gallstone pancreatitis should undergo cholecystectomy during the first admission.