Management of Gallstone Cholangitis in the Era of Laparoscopic Cholecystectomy

Abstract

Hypothesis: The combined endoscopic and laparoscopic approach is safe and effective in managing gallstone cholangitis in the era of laparoscopic cholecystectomy (LC). Design: Retrospective case series. Setting: University teaching hospital. Patients: One hundred eighty-four consecutive patients with gallstone cholangitis treated between January 1995 and December 1998. Interventions: The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed. Main Outcome Measures: Success of various interventions, morbidity and mortality, and long-term incidence of recurrent biliary symptoms. Results: Endoscopic retrograde cholangiopancreatography was successful in 175 patients (95%), with bile duct stones found in 147 (84%). Endoscopic stone clearance by ES was achieved in 132 patients (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n=3). After bile duct stone

Gallstone cholangitis

“…In conclusion, endoscopic assessment of the bile duct should be performed only in patients with a high risk of having bile duct stones. In agreement with other findings [20,22,27], our data show that patients with acute cholangitis are those who have a high risk of harboring bile duct stones.…”

“…In 1977, good results were already being obtained when endoscopic decompression was employed for the management of a particular form of cholangitis, known as "supurative cholangitis" [14], more recently, a randomized trial showed better results after endoscopic biliary drainage followed by definitive treatment than after surgical decompression [13]. An aggressive policy of early endoscopic biliary drainage resulted in a very low mortality rate [22]. On the other hand, delay in ERCP for patients with severe cholangitis resulted in increased mortality and morbidity [4].…”

“…Like other authors [22], we preferred to carry out ES in all cases because, in addition to the benifits of biliary drainage for control of sepsis, ES allows endoscopic bile duct stone removal and thus the removal of the cause of the disease. Only for patients with unstable hemodynamic status or expected difficulty of stone removal was ES postponed to a later date and initial drainage obtained by nasobiliary drainage or the insertion of an endoprosthesis to control the sepsis.…”

Laparoscopic cholecystectomy and common bile duct exploration are safe for older patients

“…Moreover, patients with larger CBD stones also are those in whom ERCP/ES most frequently fails, as observed in our experience, and those best served by a choledochotomy with a T-tube. Furthermore, patients with gallbladder left in situ after endoscopic sphincterotomy have an increased risk of recurrent biliary symptoms, which have been reported to occur in 25% of cases [17].…”

IAP Guidelines for the Surgical Management of Acute Pancreatitis

“…If a patient has had an endoscopic sphincterotomy during the course of an attack of gallstone-associated acute pancreatitis consideration should be given to removing the gallbladder as these patients have a relatively high risk of subsequent gallbladder symptoms [70][71][72][73][74].…”