Management of Gallstone Cholangitis in the Era of Laparoscopic Cholecystectomy | Hepatobiliary Disease | JAMA Surgery | JAMA Network
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Saik  RPGreenburg  AGFarris  JMPeskin  GW Spectrum of cholangitis.  Am J Surg. 1975;130143- 150Google ScholarCrossref
Saharia  PCCameron  JL Clinical management of acute cholangitis.  Surg Gynecol Obstet. 1976;142369- 372Google Scholar
Welch  JDonaldson  GA The urgency of diagnosis and surgical treatment of acute suppurative cholangitis.  Am J Surg. 1976;131527- 532Google ScholarCrossref
Boey  JHWay  LW Acute cholangitis.  Ann Surg. 1980;191264- 270Google ScholarCrossref
Thompson  JE  JrTompkins  RKLongmire  WP  Jr Factors in management of acute cholangitis.  Ann Surg. 1982;195137- 145Google ScholarCrossref
Leese  TNeoptolemos  JPBaker  ARCarr-Locke  DL Management of acute cholangitis and the impact of endoscopic sphincterotomy.  Br J Surg. 1986;73988- 992Google ScholarCrossref
Gogel  HKRunyon  BAVolpicelli  NAPalmer  RC Acute suppurative obstructive cholangitis due to stones: treatment by urgent endoscopic sphincterotomy.  Gastrointest Endosc. 1987;33210- 213Google ScholarCrossref
Leung  JWCChung  SCSSung  JJYBanez  VPLi  AKC Urgent endoscopic drainage for acute suppurative cholangitis.  Lancet. 1989;11307- 1309Google ScholarCrossref
Siegel  JHRodriquez  RCohen  SAKasmin  FECooperman  AM Endoscopic management of cholangitis: critical review of an alternative technique and report of a large series.  Am J Gastroenterol. 1994;891142- 1146Google Scholar
Lai  ECSMok  FPTTan  ESYLo  CMFan  ST Endoscopic biliary drainage for severe acute cholangitis.  N Engl J Med. 1992;3261582- 1586Google ScholarCrossref
Rosenthal  RJRossi  RLMartin  RF Options and strategies for the management of choledocholithiasis.  World J Surg. 1998;221125- 1132Google ScholarCrossref
Strasberg  SMSoper  NJ Management of choledocholithiasis in the laparoscopic era.  Gastroenterology. 1995;109320- 322Google ScholarCrossref
Perissat  JHuibregtse  KKeane  FBVRussell  RCGNeoptolemos  JP Management of bile duct stones in the era of laparoscopic cholecystectomy.  Br J Surg. 1994;81799- 810Google ScholarCrossref
MacFadyen  BV  JrPassi  RB The role of endoscopic retrograde cholangiopancreatography in the era of laparoscopic cholecystectomy.  Semin Laparosc Surg. 1997;418- 22Google Scholar
Raraty  MGTFinch  MNeoptolemos  JP Acute cholangitis and pancreatitis secondary to common duct stones: management update.  World J Surg. 1998;221155- 1161Google ScholarCrossref
Schwesinger  WHSirinek  KRStrodel  WE Laparoscopic cholecystectomy for biliary tract emergencies: state of the art.  World J Surg. 1999;23334- 342Google ScholarCrossref
Davidson  BRNeoptolemos  JPCarr-Locke  DL Endoscopic sphincterotomy for common bile duct calculi in patients with gallbladder in situ considered unfit for surgery.  Gut. 1988;29114- 120Google ScholarCrossref
Ingoldby  CJel-Saadi  JHall  RIDenyer  ME Late results of endoscopic sphincterotomy for bile duct stones in elderly patients with gall bladders in situ.  Gut. 1989;301129- 1131Google ScholarCrossref
Hill  JMartin  DFTweedle  DEF Risks of leaving the gallbladder in situ after endoscopic sphincterotomy for bile duct stones.  Br J Surg. 1991;78554- 557Google ScholarCrossref
Boender  JNix  GAde Ridder  MA  et al.  Endoscopic sphincterotomy and biliary drainage in patients with cholangitis due to common bile duct stones.  Am J Gastroenterol. 1995;90233- 238Google Scholar
Lai  ECSPaterson  IATam  PCChoi  TKFan  STWong  J Severe acute cholangitis: the role of emergency nasobiliary drainage.  Surgery. 1990;107268- 272Google Scholar
Misra  SPDwivedi  M Biliary endoprosthesis as an alternative to endoscopic nasobiliary drainage in patients with acute cholangitis.  Endoscopy. 1996;28746- 749Google ScholarCrossref
Liberman  MAPhillips  EHCarroll  BJFallas  MJRosenthal  RHiatt  J Cost-effective management of complicated choledocholithiasis: laparoscopic transcystic duct exploration or endoscopic sphincterotomy.  J Am Coll Surg. 1996;182488- 494Google Scholar
Lo  CMFan  STLiu  CLLai  ECSWong  J Early decision for conversion of laparoscopic to open cholecystectomy for treatment of acute cholecystitis.  Am J Surg. 1997;173513- 517Google ScholarCrossref
Lo  CMLiu  CLFan  STLai  ECSWong  J Prospective randomized study of early versus delayed laparoscopic cholecystectomy for acute cholecystitis.  Ann Surg. 1998;227461- 467Google ScholarCrossref
Koo  KPThirlby  RC Laparoscopic cholecystectomy in acute cholecystitis. What is the optimal timing for operation?  Arch Surg. 1996;131540- 545Google ScholarCrossref
Crawford  DLPhillips  EH Laparoscopic common bile duct exploration.  World J Surg. 1999;23343- 349Google ScholarCrossref
Tanaka  MIkeda  SYoshimoto  HMatsumoto  S The long-term fate of the gallbladder after endoscopic sphincterotomy: complete follow-up study of 122 patients.  Am J Surg. 1987;154505- 509Google ScholarCrossref
Hansell  DTMillar  MAMurray  WRGray  GRGillespie  G Endoscopic sphincterotomy for bile duct stones in patients with intact gallbladders.  Br J Surg. 1989;76856- 858Google ScholarCrossref
Kullman  EBorch  KDahlin  LGLiedberg  G Long-term follow-up of patients with gallbladder in situ after endoscopic sphincterotomy for choledocholithiasis.  Eur J Surg. 1991;157131- 135Google Scholar
Pereira-Lima  JCJakobs  RWinter  UH  et al.  Long-term results (7 to 10 years) of endoscopic papillotomy for choledocholithiasis: multivariate analysis of prognostic factors for the recurrence of biliary symptoms.  Gastrointest Endosc. 1998;48457- 464Google ScholarCrossref
Targarona  EMAyuso  RMPBordas  JM  et al.  Randomised trial of endoscopic sphincterotomy with gallbladder left in situ versus open surgery for common bile duct calculi in high-risk patients.  Lancet. 1996;347926- 929Google ScholarCrossref
Tagle  FMLavergne  JBarkin  JSUnger  SW Laparoscopic cholecystectomy in the elderly.  Surg Endosc. 1997;11636- 638Google ScholarCrossref
Lo  CMLai  ECSFan  STLiu  CLWong  J Laparoscopic cholecystectomy for acute cholecystitis in the elderly.  World J Surg. 1996;20983- 987Google ScholarCrossref
Lujan  JASanchez-Bueno  FParrilla  P  et al.  Laparoscopic vs open cholecystectomy in patients aged 65 and older.  Surg Laparosc Endosc. 1998;8208- 210Google ScholarCrossref
Original Article
January 2001

Management of Gallstone Cholangitis in the Era of Laparoscopic Cholecystectomy

Author Affiliations

From the Department of Surgery, University of Hong Kong Medical Centre, Queen Mary Hospital, Hong Kong, China.

Arch Surg. 2001;136(1):11-16. doi:10.1001/archsurg.136.1.11

Hypothesis  The combined endoscopic and laparoscopic approach is safe and effective in managing gallstone cholangitis in the era of laparoscopic cholecystectomy (LC).

Design  Retrospective case series.

Setting  University teaching hospital.

Patients  One hundred eighty-four consecutive patients with gallstone cholangitis treated between January 1995 and December 1998.

Interventions  The main treatments were endoscopic retrograde cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) followed by interval LC. Open or laparoscopic common bile duct exploration (OCBDE or LCBDE) was used when ERCP or ES failed.

Main Outcome Measures  Success of various interventions, morbidity and mortality, and long-term incidence of recurrent biliary symptoms.

Results  Endoscopic retrograde cholangiopancreatography was successful in 175 patients (95%), with bile duct stones found in 147 (84%). Endoscopic stone clearance by ES was achieved in 132 patients (90%). Morbidity rate after ERCP or ES was 4.0% (n = 7), and overall mortality rate from cholangitis was 1.6% (n = 3). After bile duct stone clearance, 82 patients underwent LC with a conversion rate of 9.8% (n = 8) and a morbidity rate of 3.6% (n = 3). Eighteen patients underwent OCBDE with a morbidity rate of 33% (n = 6), and 3 underwent LCBDE with 1 conversion and no morbidity. There was no operative mortality. Seventy-eight patients were managed conservatively after endoscopic clearance of bile duct stones. Follow-up data were available in 101 patients with cholecystectomy and 73 patients with gallbladder in situ. During a median follow-up of 24 months, recurrent biliary symptoms occurred in 5.9% (n = 6) and 25% (n = 18), respectively (P = .001). In both groups, the most common recurrent symptom was cholangitis (n = 5 and n = 14, respectively). Gallbladder in situ (risk ratio, 4.16; 95% confidence interval, 1.39-12.50; P = .01) and small-size papillotomy (risk ratio, 2.94; 95% confidence interval, 1.07-8.10; P = .04) were significant risk factors for recurrent biliary symptoms.

Conclusions  Endoscopic sphincterotomy for biliary drainage and stone removal, followed by interval LC, is a safe and effective approach for managing gallstone cholangitis. Patients with gallbladder left in situ after ES have an increased risk of recurrent biliary symptoms. Laparoscopic cholescystectomy should be recommended after endoscopic management of cholangitis except in patients with prohibitive surgical risk.