LINICAL – LIVER , PANCREAS , AND BILIARY TRACT holecystectomy or Gallbladder In Situ After Endoscopic phincterotomy and Bile Duct Stone Removal in hinese Patients

ackground & Aims: In patients with stones in their ile ducts and gallbladders, cholecystectomy is genrally recommended after endoscopic sphincterotomy nd clearance of bile duct stones. However, only aproximately 10% of patients with gallbladders left in itu will return with further biliary complications. Exectant management is alternately advocated. In this tudy, we compared the treatment strategies of lapaoscopic cholecystectomy and gallbladders left in situ. ethods: We randomized patients (>60 years of age) fter endoscopic sphincterotomy and clearance of heir bile duct stones to receive early laparoscopic holecystectomy or expectant management. The priary outcome was further biliary complications. ther outcome measures included adverse events afer cholecystectomy and late deaths from all causes. esults: One hundred seventy-eight patients entered nto the trial (89 in each group); 82 of 89 patients who ere randomized to receive laparoscopic cholecystecomy underwent the procedure. Conversion to open urgery was needed in 16 of 82 patients (20%). Postperative complications occurred in 8 patients (9%). nalysis was by intention to treat. With a median ollow-up of approximately 5 years, 6 patients (7%) in he cholecystectomy group returned with further biliry events (cholangitis, n 5; biliary pain, n 1). mong those with gallbladders in situ, 21 (24%) reurned with further biliary events (cholangitis, n 13; cute cholecystitis, n 5; biliary pain, n 2; and aundice, n 1; log rank, P .001). Late deaths were imilar between groups (cholecystectomy, n 19; allbladder in situ, n 11; P .12). Conclusions: In he Chinese, cholecystectomy after endoscopic treatent of bile duct stones reduces recurrent biliary vents and should be recommended. ndoscopic sphincterotomy and stone extraction have gained wide acceptance in the management of bile uct stones. Complete stone removal after endoscopic phincterotomy can be achieved in 90% of cases with ow morbidity and negligible mortality.1 After endocopic removal of bile duct stones, the need for choleystectomy in patients with concomitant gallstones is isputed. Many contend that endoscopic management of ile duct stones with gallbladders left in situ is definitive n elderly and high-risk patients. Retrospective and propective series have suggested that further biliary comlications occur in 4%–24% of patients after varying eriods of follow-up, and the rate of subsequent choleystectomy is 5.8%–18%.2–8 As a treatment of the comlication of biliary pancreatitis, ablation of the sphincter llows free passage of stones into the duodenum. Endocopic sphincterotomy may in itself be definitive in rophylaxis against further attacks. Many advocate for a single-stage cholecystectomy and ile duct exploration as the primary treatment of bile uct stones. The strategy was compared with endoscopic reatment in 2 randomized studies. Hammarstrom et al9 andomized 83 patients and found that recurrent biliaryelated events occurred in 28% of patients initially reated by endoscopy compared with 5% in those who nderwent open cholecystectomy and bile duct exploraion. In a similar study involving 98 patients with a ean age of 80 years, recurrent biliary symptoms ocurred in fewer patients treated by operation (3 of 48 vs 0 of 50).10 Both studies concluded that surgery would