Prophylactic cholecystectomy offers best outcomes following ERCP clearance of common bile duct stones: a meta-analysis

Abstract

Background Symptomatic calculus biliary disease is common with associated morbidity and occasional mortality, further confounded when there is concomitant common bile duct (CBD) stones. Choledocholithiasis and clearance of the duct reduces recurrent cholangitis, but the question is whether after clearance of the CBD if there is a need to perform a cholecystectomy. This meta-analysis evaluated outcomes in patients undergoing ERCP with or without sphincterotomy to determine if cholecystectomy post-ERCP clearance offers optimal outcomes over a wait-and-see approach. Methods A Prospero registered meta-analysis of the literature using PRISMA guidelines incorporating articles related to ERCP, choledocholithiasis, cholangitis and cholecystectomy was undertaken for papers published between 1st January 1991 and 31st May 2021. Existing research that demonstrates outcomes of ERCP with no cholecystectomy versus ERCP and cholecystectomy was reviewed to determine the related key events, complications and mortality of leaving the gallbladder in situ and removing it. Odds ratios (OR) were calculated using Review Manager Version 5.4 and meta-analyses performed using OR using fixed-effect (or random-effect) models, depending on the heterogeneity of studies. Results 13 studies (n = 2598), published between 2002 and 2019, were included in this meta-analysis, 6 retrospective, 2 propensity score-matched retrospective studies, 3 prospective studies and 2 randomised control trials from a total of 11 countries. There were 1433 in the no cholecystectomy cohort (55.2%) and 1165 in the prophylactic cholecystectomy (44.8%) cohort. Cholecystectomy resulted in a decreased risk of cholecystitis (OR = 0.15; CI 0.07–0.36; p < 0.0001), cholangitis (OR = 0.51; CI 0.26–1.00; p = 0.05) and mortality (OR = 0.38; CI 0.16–0.9; p = 0.03). In addition, prophylactic cholecystectomy resulted in a significant reduction in biliary events, biliary pain and pancreatitis. Conclusions In patients undergoing CBD clearance, consideration should be given to performing prophylactic cholecystectomy to optimise outcomes.

Long-Term Risks of Benign and Malign Complications after Endoscopic Sphincterotomy in the Management of Benign Biliopancreatic Pathology: A Cohort Study

“… 17 Surprisingly, we found that having undergone cholecystectomy (either before or after ERCP) increased the risk of developing long-term benign complications. These findings contrast with what has been reported in other studies, 18 where post-ERCP cholecystectomy is associated with an overall decrease in biliopancreatic complications following ERCP.…”

Current management of concomitant cholelithiasis and common bile duct stones

“…A recent meta-analysis showed that prophylactic cholecystectomy after ERCP- endoscopic sphincterotomy (ERCP-ES) CBD stone clearance was better than the wait-and-see policy. It was associated with fewer complications (acute cholecystitis, acute cholangitis, acute pancreatitis and biliary colic)[ 12 ]. However, it should be particularly considered in extremely elderly patients with limited life expectancy or unfit frail patients.…”