Clearing Common Bile Duct Stones: A Viewpoint
Clearing Common Bile Duct Stones: A Viewpoint
Martin DJ, Vernon DR, Toouli J
Cochrane Database Syst Rev. 2006;(2):CD003327
Background: 10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery.
Objectives: To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy. SEARCH STRATEGY: We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005.
Selection Criteria: The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up.
Data Collection and Analysis: Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required.
Main Results: Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis.
Authors' Conclusions: In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.
What is the best strategy for managing CBD stones in patients with stones in the gallbladder? When an open abdominal operation was the usual method for treating gallbladder disease, the preferred method was open exploration of the bile ducts with stone extraction. In the era of laparoscopic surgery, there are more choices: laparoscopic bile duct exploration or stone removal via ERCP, with ERCP carried out either before or after laparoscopic cholecystectomy. This report by the Cochrane group reviewed 3974 articles from which 13 randomized trials were selected for extensive review. After open cholecystectomy, open bile duct surgery is preferable to ERCP. At present, when most biliary tract surgery is performed laparoscopically, there appears to be little difference in results following either laparoscopic or ERCP management of common duct stones. The laparoscopic approach avoids another procedure by an additional group of specialists; however, it does require greater experience for accurate performance of the procedure.
Abstract
Martin DJ, Vernon DR, Toouli J
Cochrane Database Syst Rev. 2006;(2):CD003327
Background: 10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct (CBD) stones. Treatment options for these stones include pre- or post-operative endoscopic retrograde cholangiopancreatography (ERCP) or open or laparoscopic surgery.
Objectives: To systematically review the management of CBD stones by four approaches: (1) ERCP versus open surgical bile duct clearance. (2) Pre-operative ERCP versus laparoscopic bile duct clearance. (3) Post-operative ERCP versus laparoscopic bile duct clearance. (4) ERCP versus laparoscopic bile duct clearance in patients with previous cholecystectomy. SEARCH STRATEGY: We systematically searched key relevant electronic databases, bibliographies of relevant papers, and abstracts of relevant subspecialty meetings until November 2005.
Selection Criteria: The quality of included trials was assessed by adequacy of allocation sequence generation, allocation concealment, blinding, and follow-up.
Data Collection and Analysis: Published and unpublished data relevant to 12 predefined outcome measures were used to conduct fixed- and random-effects models meta-analyses, with exploration of heterogeneity and use of sensitivity and subgroup analysis where required.
Main Results: Thirteen trials randomised 1351 patients. Eight trials (n = 760) compared ERCP with open surgical clearance, three (n = 425) compared pre-operative ERCP with laparoscopic clearance, and two (n = 166) compared post-operative ERCP with laparoscopic clearance. There were no trials of ERCP versus laparoscopic clearance in patients without an intact gallbladder. Methodology was considered adequate in at least two of three assessable fields in ten trials. A significantly increased number of total procedures (including for complications) per patient was seen in the ERCP arms in all three comparisons with weighted mean differences of 0.62 (95% CI 0.15 to 1.09), 0.96 (95% CI 0.96 to 0.96), and 1.09 (95% CI 0.93 to 1.24), respectively. ERCP was less successful than open surgery in CBD stone clearance (Peto OR 2.89, 95% CI 1.81 to 4.61) with a tendency towards higher mortality (risk difference 1%, 95% CI -1% to 4%). Laparoscopic CBD stone clearance was as efficient as pre- (Peto OR 1.00, CI 0.53 to 1.80) and post-operative ERCP (OR 2.27, 95% CI 0.37 to 13.9) and with no significant difference in morbidity and mortality. Laparoscopic trials universally reported shorter hospital stays in surgical arms. Insufficient data were reported for cost analysis.
Authors' Conclusions: In the era of open cholecystectomy, open bile duct surgery was superior to ERCP in achieving CBD stone clearance. In the laparoscopic era, data are close to excluding a significant difference between laparoscopic and ERCP clearance of CBD stones. The use of ERCP necessitates increased number of procedures per patient.
What is the best strategy for managing CBD stones in patients with stones in the gallbladder? When an open abdominal operation was the usual method for treating gallbladder disease, the preferred method was open exploration of the bile ducts with stone extraction. In the era of laparoscopic surgery, there are more choices: laparoscopic bile duct exploration or stone removal via ERCP, with ERCP carried out either before or after laparoscopic cholecystectomy. This report by the Cochrane group reviewed 3974 articles from which 13 randomized trials were selected for extensive review. After open cholecystectomy, open bile duct surgery is preferable to ERCP. At present, when most biliary tract surgery is performed laparoscopically, there appears to be little difference in results following either laparoscopic or ERCP management of common duct stones. The laparoscopic approach avoids another procedure by an additional group of specialists; however, it does require greater experience for accurate performance of the procedure.
Abstract