REFILE-Study favors aggressive management for common bile duct stones

Last Updated: 2014-08-26

(Corrects demographics of cohort, by replacing second sentence in para 4.)

By James E Barone MD

NEW YORK (Reuters Health) - Doctors should try to clear the bile ducts when stones are found on intraoperative cholangiography, Swedish researchers say.

In a review of data from more than 3,800 patients with common bile duct stones, they saw more unfavorable outcomes in those patients who had no attempts to clear the stones either intraoperatively or postoperatively.

A number of small studies have suggested that stones often clear spontaneously without complications, suggesting a wait-and-see approach may be worthwhile. But they sometimes cause serious morbidity, and many surgeons have traditionally favored aggressive treatment, Dr. Anders Thorell and colleagues write in JAMA Surgery, online August 13.

Their study is based on data from a registry that includes about 90% of cholecystectomies performed in that country. Of the 3,828 patients in the analysis, 49.1% had been admitted for acute illnesses, and 51.2% had symptoms related to common bile duct stones.

In 90% of patients, the size of the largest common duct stone was recorded in the registry, and the stones were divided into three groups: less than 4 mm, 4 to 8 mm, and greater than 8 mm.

Unfavorable outcomes such as postoperative pancreatitis, cholangitis or bile duct obstruction were found in 11.2% of patients with stones less than 4 mm in diameter. They grew more common as stone size increased, with 15.3% and 18.7% of patients with mid-size and larger stones, respectively, having unfavorable outcomes.

Seven different treatment strategies to deal with the common duct stones were found in the registry, including no intraoperative or postoperative procedures, intraoperative or postoperative endoscopic retrograde cholangiopancreatography (ERCP), intraoperative flushing or manipulation, laparoscopic or open choledochotomy, and transcystic extraction.

When nothing was done (594 patients), unfavorable outcomes occurred 25.3% of the time compared to 12.7% of the time when any of the other six treatment choices were used (3,234 patients); among the interventions, the rate of unfavorable outcomes was lowest for laparoscopic choledochotomy (5.7%) and highest for open choledochotomy (18.1%).

Overall, this represents a significant risk reduction for the six procedures combined versus no procedures (OR, 0.44).

The authors acknowledged several limitations of their study. Apart from its retrospective nature, it also didn't include the number of common duct stones found on intraoperative cholangiography. And neither preoperative treatment of common bile duct stones nor data on patients with missed stones were included.

Partly based on the findings, Dr. Thorell's group tries to remove all common bile duct stones.

"If the stones are small, we try to flush or manipulate the stones, and if this is not successful, we usually prefer laparoscopic transcystic extraction as second choice," he told Reuters Health by email.

Whereas routine intraoperative cholangiography during cholecystectomy is performed at most hospitals in Sweden, this is not necessarily the case in the U.S.

"Practice varies in the US, but increasing literature including from my group (J Gastrointest Surg. 2013;17:434-42) and others suggests it is not associated with better outcomes," said Dr. Jennifer F. Tseng, chief of the division of surgical oncology at Beth Israel Deaconess Medical Center in Boston, who was not involved in the Swedish research.

Dr. Tseng said she uses intraoperative duct flushing, and intravenous glucagon, followed by repeat imaging. For tiny stones or minimal sludge, she checks liver function studies and follows the clinical exam, and for medium or larger stones, she uses postoperative ERCP with sphincterotomy.

SOURCE: http://bit.ly/1kHhM8C

JAMA Surg 2014