Practice Patterns for Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography for Patients With Choledocholithiasis

Abstract

Background & Aims Cholecystectomy (CCY) following an episode of choledocholithiasis requiring endoscopic retrograde cholangio-pancreatography (ERCP) with stone extraction reduces recurrent biliary events, compared to expectant management. We studied practice patterns for performance of CCY following ERCP for choledocholithiasis using data from 3 large states and evaluated the effects of delaying CCY. Methods We conducted a retrospective cohort study using the ambulatory surgery, inpatient, and emergency department databases from the states of California (years 2009–2011), New York (2011–2013), and Florida (2012–2014). We collected data from 4516 patients hospitalized with choledocholithiasis who underwent ERCP. We compared outcomes of patients who underwent CCY at index admission (early CCY), elective CCY within 60 days of discharge (delayed CCY), or did not undergo CCY (no CCY), calculating rate of recurrent biliary events (defined as an emergency department visit or unplanned hospitalization due to symptomatic cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis), mortality, and cost by CCY cohort. We also evaluated risk factors for not undergoing CCY. The primary outcome measure was the rate of recurrent biliary events in the 365 days following discharge from index admission. Results Of the patients who underwent ERCP for choledocholithiasis, 41.2% underwent early CCY, 10.9% underwent delayed CCY, and 48.0% underwent no CCY. Early CCY reduced relative risk of recurrent biliary events within 60 days by 92%, compared with delayed or no CCY (P<.001). After 60 days following discharge from index admission, patients with early CCY had an 87% lower risk of recurrent biliary events than patients with no CCY (P<.001) and patients with delayed CCY had an 88% lower risk of recurrent biliary events than patients with no CCY (P<.001). A strategy of delayed CCY performed on an outpatient basis was least costly. Performance of early CCY was inversely associated with low facility volume. Hispanic race, Asian race, Medicaid insurance, and no insurance associated inversely with performance of delayed CCY. Conclusions In a retrospective analysis of over 4500 patients hospitalized with choledocholithiasis, we found that CCY was not performed following ERCP for almost half of the cases. Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of recurrent biliary event while waiting for a delayed CCY compared with patients who underwent early CCY. Delayed CCY is a cost-effective strategy that must be balanced against the risk of loss to follow up, particularly among patients who are ethnic minorities or have little or no health insurance.

Single-stage treatment with ERCP and laparoscopic cholecystectomy versus two-stage treatment with ERCP followed by laparoscopic cholecystectomy within six to eight weeks: a retrospective study

“…Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of a recurrent biliary event while waiting for a delayed cholecystectomy compared to patients who underwent early cholecystectomy (15). In our study, recurrent biliary episodes were not detected in patients who underwent ERCP and LC at the same session.…”

Protocol for a randomized trial of the effect of timing of cholecystectomy during initial admission for predicted mild gallstone pancreatitis at a safety-net hospital

“… 33 On the other hand, Hispanic patients are more likely to require ERCP 34 and have increased delays to cholecystectomy after ERCP for choledocholithiasis. 35 These data suggest that Hispanic patients may be an ideal population in whom to study this question as they may be most likely to benefit.…”

Trends in the timing of inpatient ERCP relative to cholecystectomy: a nationwide database studied longitudinally

“…Historically, choledocholithiasis was treated during CCY via CBDE; ERCP has largely replaced CBDE because of diminished expertise in laparoscopic CBDE, wider availability of ERCP services, and reasonable morbidity profile of ERCP, among other unknown factors. 1,12 An obvious advantage of CBDE is the ability to remove the gallbladder and clear the common bile duct in one setting. However, this is challenging to operationalize because CBDE undoubtedly prolongs procedure and recovery times (especially when it is unplanned and follows a positive IOC), and has greater morbidity to laparoscopic CCY alone.…”