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

Martin DJ, Vernon D, Toouli J

Published Online:

January 21, 2009

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.

Abstract (click to read)

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 strategy:

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Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use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

This record should be cited as:

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

Assessed as up to date:

February 21, 2006

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Primary Review Group:

Hepato-Biliary Group

Health topics:

Gastroenterology > Gall stone disease > Common bile duct-located

Cochrane Summaries^beta

Independent high-quality evidence for health care decision making

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

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