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The role of prophylactic cholecystectomy versus deferral in the care of patients after endoscopic sphincterotomy.

AbstractINTRODUCTION:
Prophylactic cholecystectomy (PC) is advised after ES and clearance of ductal calculi on the basis of a randomized controlled trial that showed a requirement for cholecystectomy in 36% of patients who defer surgery. Other studies suggest the cholecystectomy rate to be as low as 8%.
METHOD:
To determine the proportion of patients who deferred cholecystectomy and the outcome, we reviewed 870 consecutive patients who underwent endoscopic retrograde cholangiography and sphincterotomy; the gallbladder of 420 of these remained in situ. Patients were assigned to PC or deferred cholecystectomy (DC) groups.
RESULTS:
Cholecystectomy was deferred in 180 of 310 eligible patients. DC patients were significantly older (66.4 v. 49.8 yr) and sicker (according to the American Society of Anesthesiology [ASA] physiological status score) and had a significantly higher mortality rate than did PC patients. Deaths were principally cardiovascular and not biliary related. After a follow-up of 24.2 (<1-82.3) months, eventual cholecystectomy was required in 46 (24.7%) DC patients at a mean of 6 months after ES. The subgroup undergoing eventual cholecystectomy was younger (57.6 v. 69.4 yr; p<0.001) fitter (ASA score of 1.98 v. 2.26; p=0.015) and more likely to have residual cholecystolithiasis than were those who continued deferral. Recurrent pancreatitis was more common in DC (30%) than in PC (4.8%) patients if pancreatitis was the indication for sphincterotomy.
DISCUSSION:
PC is advised for patients with residual cholecystolithiasis after ES. In patients with relative contraindications, the choice is balanced in favour of cholecystectomy if there is a history of pancreatitis and in favour of deferral if more than 6 months have elapsed since ES.
AuthorsJason D Archibald, Jonathan R Love, Vivian C McAlister
JournalCanadian journal of surgery. Journal canadien de chirurgie (Can J Surg) Vol. 50 Issue 1 Pg. 19-23 (Feb 2007) ISSN: 0008-428X [Print] Canada
PMID17391611 (Publication Type: Journal Article)
Topics
  • Age Factors
  • Aged
  • Cause of Death
  • Cholangiopancreatography, Endoscopic Retrograde
  • Cholecystectomy
  • Cholecystolithiasis (complications)
  • Cholelithiasis (surgery)
  • Cohort Studies
  • Follow-Up Studies
  • Humans
  • Middle Aged
  • Patient Compliance
  • Physical Fitness
  • Retrospective Studies
  • Severity of Illness Index
  • Sphincterotomy, Endoscopic
  • Survival Rate
  • Treatment Outcome
  • Treatment Refusal

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