Division of Gastroenterology and Hepatology, University of Alabama at Birmingham, Birmingham, AL.
Division of Gastroenterology and Hepatology.
J Clin Gastroenterol. 2018 Aug;52(7):579-589. doi: 10.1097/MCG.0000000000001076.
Endoscopic retrograde cholangiography and endoscopic sphincterotomy (ES) with subsequent cholecystectomy is the standard of care for the management of patients with choledocholithiasis. There is conflicting evidence in terms of mortality reduction, prevention of complications specifically biliary pancreatitis and cholangitis with the use of early cholecystectomy particularly in high-risk surgical and elderly patients.
We conducted this systematic review and meta-analysis of randomized controlled trials to compare the early cholecystectomy versus wait and watch strategy after ES.
We searched Medline, Scopus, Web of Science, and Cochrane database for randomized controlled trials comparing the 2 strategies in the management of choledocholithiasis after ES. Our primary outcome of interest was difference in mortality. We evaluated several secondary outcomes including difference in development of acute pancreatitis, biliary colic and cholecystitis, cholangitis and recurrent jaundice, nonbiliary adverse events, and length of hospital stay. Risk ratios (RR) were calculated for categorical variables and difference in means was calculated for continuous variables. These were pooled using random effects model.
Seven studies with 916 patients (455 cholecystectomy group and 461 wait and watch group) were included in the meta-analysis. Pooled RR with 95% confidence interval for mortality was 1.43 (0.93-2.18), I=9%. In the high-risk patient group, pooled RR was 1.39 (0.64-3.03) and in low-risk population pooled RR was 1.53 (0.79-2.96). Pooled RR for acute pancreatitis was 1.64 (0.46-5.81) with no heterogeneity. There was no difference in the rate of acute pancreatitis patients based on high-risk versus low-risk patients. Pooled RR for occurrence of biliary colic and cholecystitis during follow-up was 9.82 (4.27-22.59), I=0%. Pooled RR for cholangitis and recurrent jaundice was 2.16 (1.14-4.07), I=0%. However, there was no difference in the rate of cholangitis between the 2 groups in low-risk patients. Length of stay was shorter in the wait and watch group with a pooled mean difference was -2.70 (-4.71, -0.70) with substantial heterogeneity.
Although we found no difference in mortality between the 2 strategies after ES, laparoscopic cholecystectomy should be recommended as it is associated with lower rates of subsequent recurrent cholecystitis, cholangitis, and biliary colic down the road even in high-risk surgical patients.
内镜逆行胰胆管造影术（ERCP）和内镜下括约肌切开术（ES）联合随后的胆囊切除术是治疗胆总管结石的标准治疗方法。在使用早期胆囊切除术（尤其是在高风险手术和老年患者中）降低死亡率、预防特定并发症（如胆源性胰腺炎和胆管炎）方面，存在相互矛盾的证据。
我们进行了这项系统评价和荟萃分析，以比较 ERCP 后早期胆囊切除术与等待观察策略。
我们在 Medline、Scopus、Web of Science 和 Cochrane 数据库中搜索了比较 ES 后 2 种策略治疗胆总管结石的随机对照试验。我们感兴趣的主要结局是死亡率的差异。我们评估了几个次要结局，包括急性胰腺炎、胆绞痛和胆囊炎、胆管炎和复发性黄疸、非胆源性不良事件以及住院时间的差异。对于分类变量，计算风险比（RR），对于连续变量，计算平均值的差异。使用随机效应模型对这些数据进行汇总。
荟萃分析纳入了 7 项研究，共 916 名患者（455 名接受胆囊切除术组和 461 名等待观察组）。死亡率的合并 RR 和 95%置信区间为 1.43（0.93-2.18），I=9%。在高危患者组中，合并 RR 为 1.39（0.64-3.03），在低危人群中，合并 RR 为 1.53（0.79-2.96）。合并 RR 用于急性胰腺炎为 1.64（0.46-5.81），无异质性。高危患者与低危患者的急性胰腺炎发生率无差异。在随访期间，胆绞痛和胆囊炎的发生率合并 RR 为 9.82（4.27-22.59），I=0%。胆管炎和复发性黄疸的合并 RR 为 2.16（1.14-4.07），I=0%。然而，在低危患者中，两组的胆管炎发生率没有差异。等待观察组的住院时间较短，合并平均差异为-2.70（-4.71，-0.70），存在显著异质性。
尽管我们发现 ERCP 后两种策略之间的死亡率没有差异，但由于即使在高风险手术患者中，它也与较低的后续复发性胆囊炎、胆管炎和胆绞痛发生率相关，因此应推荐腹腔镜胆囊切除术。
