Reuters Health Information: REFILE-Study favors aggressive management for common bile duct stones
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
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
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
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
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.
JAMA Surg 2014