Single-Stage Endoscopic Stone Extraction and Cholecystectomy during the Same Hospitalization: What is the Optimal Strategy for Patients with Choledocholithiasis and Cholelithiasis?

Abstract

Up to 18% of patients who undergo cholecystectomy for gallstones have concomitant choledocholithiasis; thus, these patients are referred for endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy. However, practice patterns in patients with choledocholithiasis and cholelithiasis are still largely institution-based, depending on the institutional resource constraints. Some have advocated combining ERCP with cholecystectomy during the same admission, while others have argued that ERCP and cholecystectomy should be delayed to minimize postoperative adverse events. Although single-stage endoscopic stone extraction is accepted as the standard strategy for treatment of patients with choledocholithiasis, some endoscopists, especially in Japan, still prefer to perform endoscopic drainage and stone removal separately. In this issue of Clinical Endoscopy, Terauchi et al. compared the clinical outcomes of subjects who underwent cholecystectomy at index admission (n=106) or during a subsequent hospitalization (n=13). They also investigated the efficacy and safety of single-stage ERCP. Although there is no consensus regarding the optimal timing for cholecystectomy after endoscopic stone removal, the most time-efficient approach is performing ERCP and cholecystectomy during the same hospitalization. A recent study from the US compared the clinical outcomes of 4,516 patients who underwent cholecystectomy at index admission (41.2%), elective cholecystectomy within 60 days after discharge (10.9%), or no cholecystectomy (48.0%) and evaluated the incidence of recurrent biliary events, mortality, and cost. Surprisingly, nearly half of the patients did not undergo a subsequent cholecystectomy during or after hospitalization. Early cholecystectomy was protective against the relative risk of recurrent biliary events within 2 months by 92%, compared with delayed or no cholecystectomy (p<0.001). Two months after the initial discharge, the delayed cholecystectomy group had an 88% lower risk of recurrent biliary events than the no cholecystectomy group (p<0.001). Although either early or delayed cholecystectomy reduces recurrent biliary events, the delayed cholecystectomy group showed a 10-fold higher risk of recurrent biliary events while waiting for an interval cholecystectomy than that in the early cholecystectomy group. Unlike previous studies, Terauchi et al. showed that there were no significant differences between the early and delayed cholecystectomy groups in terms of operative time, rate of postoperative complications, and interval from cholecystectomy to discharge and could not demonstrate that early cholecystectomy is superior to delayed cholecystectoReceived: December 10, 2018 Accepted: December 10, 2018 Correspondence: Tae Yoon Lee Division of Gastroenterology, Department of Internal Medicine, Konkuk University School of Medicine, 120-1 Neungdong-ro, Gwangjin-gu, Seoul 05030, Korea Tel: +82-2-2030-7497, Fax: +82-2-2030-7458, E-mail: [email protected] ORCID: https://orcid.org/0000-0003-1008-9814