Clinical question
Which strategy — initial cholecystectomy or common duct endoscopic investigation followed by cholecystectomy — leads to better outcomes in the treatment of suspected common duct stones?
Bottom line
As compared with a strategy of sequential common duct endoscopy followed by surgery, the use of initial cholecystectomy with intraoperative cholangiogram for patients at intermediate risk of choledocholithiasis leads to shorter hospital length of stay and fewer interventions with otherwise comparable outcomes. (LOE = 1b)
Reference
Iranmanesh P, Frossard J, Mugnier-Konrad B, et al. Initial cholecystectomy vs. sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration. JAMA 2014;312(2):137-144.
Study design
Randomized controlled trial (nonblinded)
Funding source
Unknown/not stated
Allocation
Concealed
Setting
Inpatient (any location) with outpatient follow-up
Synopsis
The role of common duct endoscopic investigation prior to cholecystectomy for patients at intermediate risk of choledocholithiasis is questionable as stones often migrate into the duodenum without such intervention. Using concealed allocation, investigators randomized 100 patients who presented to an emergency department with clinical suspicion of choledocholithiasis (right upper quadrant or epigastric abdominal pain with elevated liver function test results and ultrasound-confirmed gallstone) to 1 of 2 groups. The study group underwent primary cholecystectomy with intraoperative cholangiogram, while the classical treatment group first had common duct exploration with magnetic resonance cholangiopancreatography (MRCP), endoscopic ultrasound (EUS), and endoscopic retrograde cholangiopancreatography (ERCP), if needed, followed by cholecystectomy. The authors excluded patients with severe sepsis, pancreatitis, bilirubinemia greater than 4 mg/dL, or proven common duct stones on admission. The 2 groups had similar baseline characteristics, including similar preoperative health status scores. Overall, the number of confirmed common duct stones in each group was approximately 20%. Patients in the cholecystectomy-first group had a significantly shorter hospital length of stay than the classical treatment group (5 days vs 8 days; P < .001) and also had fewer common duct investigations (MRCP, EUS, or ERCP; 25 vs 71; P < .001). There were no significant differences detected between the 2 groups in quality-of-life assessments or in surgical or medical complications within 6 months.
Dr. Kulkarni is an assistant professor of hospital medicine at Northwestern University in Chicago.