Prospective validation of an initial cholecystectomy strategy for patients at intermediate-risk of common bile duct stone

Abstract

Background and aims: Initial cholecystectomy for patients at intermediate risk of common bile duct (CBD) stones (including increased liver function tests but bilirubin <4 mg/dL and no cholangitis) showed shorter length of stay and fewer CBD investigations without increased morbidity compared with sequential CBD endoscopic assessment and subsequent cholecystectomy in a randomized controlled trial. The objectives were to prospectively validate these results in daily clinical practice and discuss current guidelines.

Methods: Initial cholecystectomy has become the standard management strategy at Geneva University Hospitals since July 2013 for patients at intermediate risk of CBD stones admitted with acute gallstone-related conditions. Between July 2013 and December 2014, length of stay, number of CBD investigations, and number of adverse events were recorded for these patients and compared with the data of the patients in the randomized controlled trial.

Results: Data for 161 consecutive newly assessed patients at intermediate risk of CBD stones confirmed shorter length of stay (7.6 vs 9.8 days; P < .001), fewer CBD investigations (0.8 vs 1.4 investigations per patient; P < .001), and similar adverse event rates (5.6% vs 14%, P = .14 including all adverse events; 3.1% vs 8%, P = .22 including only grade ≥III adverse events, defined by endoscopic/surgical reintervention or intensive care unit admission) compared with the previously reported group of patients who underwent preoperative CBD investigations.

Conclusions: These data confirm that initial cholecystectomy results in a shorter length of stay without increased morbidity among patients at intermediate risk of CBD stones compared with sequential CBD assessment and subsequent cholecystectomy. This approach may change current guidelines.