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

INTRODUCTION

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.