Among patients with possible common duct stones, removal of the gall bladder, compared with endoscopic assessment of the common duct followed by gall bladder removal, resulted in a shorter length of hospital stay without increased illness and fewer common duct examinations, according to a study in the July 9 issue of JAMA.
Many common duct stones eventually pass into the duodenum (a section of the small intestine just below the stomach), making preoperative common duct investigations unnecessary. Conversely, a strategy of gall bladder removal first can lead to the discovery of a retained common duct stone during surgery. It is uncertain what is the best initial strategy for treating this condition, according to background information in the article.
Pouya Iranmanesh, M.D., of Geneva University Hospital and Faculty of Medicine, Geneva, Switzerland, and colleagues randomly assigned 100 patients with possible common duct stones to undergo immediate laparoscopic cholecystectomy (gall bladder removal) with intraoperative cholangiogram (an imaging technique using a dye injection to evaluate the common duct) or endoscopic common duct evaluation followed by cholecystectomy, with patient follow-up of 6 months.
Patients who underwent cholecystectomy as a first step (study group) had a significantly shorter median length of hospital stay (5 days vs 8 days) compared to patients in the control group. In addition, the total number of common duct investigations (various procedures to look for stones in the common duct) performed in the study group was smaller (25 vs 71). Overall, complications were observed in 8 percent of patients in the study group and 14 percent in the control group. There was no significant difference in illness or quality of life measures between groups.
The authors note that overall, 60 percent of patients in the study group did not need any common duct investigation after the intraoperative cholangiogram. “Thus, many intermediate-risk patients undergo unnecessary preoperative common duct procedures.”
The researchers add that although a thorough cost analysis was beyond the scope of this study, the significantly shorter length of hospital stay and fewer common duct investigations in the study group, coupled with the similar complication rates between the 2 groups, predicts substantial savings when using a cholecystectomy-first strategy.
“If these findings are confirmed, initial cholecystectomy with intraoperative cholangiogram may be a preferred approach,” the authors conclude.
Pouya Iranmanesh MD, Jean-Louis Frossard MD, Béatrice Mugnier-Konrad , Philippe Morel MD, Pietro Majno MD, Thai Nguyen-Tang MD, Thierry Berney MD, Gilles Mentha MD, Christian Toso MD, PhD. Initial Cholecystectomy vs Sequential Common Duct Endoscopic Assessment and Subsequent Cholecystectomy for Suspected Gallstone Migration: A Randomized Clinical Trial. JAMA. 2014; 312(2):137-144. doi:10.1001/jama.2014.7587
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