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Journal of Minimally Invasive Surgery 2022; 25(1): 7-8
Published online March 15, 2022
https://doi.org/10.7602/jmis.2022.25.1.7
© The Korean Society of Endo-Laparoscopic & Robotic Surgery
One-stage versus two-stage approach for concomitant gallbladder and common bile duct stones: which one is more proper in patients over 80 years old?
Seung Eun Lee 
Correspondence to : Seung Eun Lee
Department of Surgery, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea
Tel: +82-2-6299-1545
Fax: +82-2-824-7869
E-mail: selee508@cau.ac.kr
ORCID:
https://orcid.org/0000-0003-1830-9666
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
At present, the optimal treatment for common bile duct (CBD) stones combined with gallstones is still controversial. The two most widely accepted techniques are one-stage laparoscopic CBD exploration plus laparoscopic cholecystectomy (LC) and two-stage preoperative endoscopic sphincterotomy plus LC. Considering that all current evidence comes from nonrandomized controlled trials, multicenter randomized controlled trials are needed to further establish the treatment strategy for elderly patients with CBD stones combined with gallstones.
Keywords Gallstones, Common bile duct, Laparoscopic cholecystectomy, Endoscopic sphincterotomy
Since the introduction of laparoscopic cholecystectomy (LC), the optimal treatment for common bile duct (CBD) stones combined with gallstones, a condition known as cholecysto-choledocholithiasis (CCL), remained controversial for years despite the results of several randomized controlled trials comparing one-stage laparoscopic CBD exploration (LCBDE) plus LC (LCBDE + LC) and two-stage preoperative endoscopic retrograde cholangiopancreatography with sphincterotomy plus LC (pre-ERCP + LC) [1–8]. In general, the one-stage procedure is expected to reduce the overall hospital stay and cost, albeit being highly technically demanding. Especially, elderly patients had higher incidences of cardiovascular disease and pulmonary disease, as well as higher grades of American Society of Anesthesiologists physical status classification, implying that they might have greater potential risks for laparoscopic surgery and general anesthesia than young patients. The two-stage procedure is associated with a higher CBD stone clearance and lower postoperative bile leakage, while a higher rate of pancreatitis is associated with endoscopic procedure. In addition, ERCP-caused dysfunction of the sphincter of Oddi can be permanent, leading to damage of the sphincter barrier and duodenobiliary reflux.
For elderly patients, choosing the best treatment strategy between two procedures is a more difficult process than young patients because elderly patients typically have underlying chronic diseases and age-specific deterioration of organ function. Consequently, they are classified as a high-risk group for surgery under general anesthesia. Furthermore, elderly patients are associated with high morbidity during the perioperative period, so endoscopic alternatives may be preferred. However, the risk of ERCP-associated complications also increases in elderly patients, and their cooperation can be limited due to physical or mental impairments and anatomical complexities, such as periampullary diverticula, which increase the failure rate of endoscopic procedures.
This study compared one-stage LCBDE + LC and two-stage pre-ERCP + LC for patients with CCL over 80 years of age [9]. The results showed no significant difference between these approaches in terms of treatment safety and efficacy such as postoperative morbidity and hospital stay. However, in the one-stage LCBDE + LC group, there were more patients with previous gastrectomy, multiple large (≥15 mm) CBD stones, or the inability to cooperate with endoscopic procedures. Importantly, this study indicates that the one-stage LCBDE + LC is a better treatment option for elderly patients with these conditions.
Conflict of interest
The author has no conflicts of interest to declare.
Funding/support
None.
REFERENCES
- Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952-957.
- Sgourakis G, Karaliotas K. Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir 2002;57:467-474.
- Noble H, Tranter S, Chesworth T, Norton S, Thompson M. A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A 2009;19:713-720.
- Rogers SJ, Cello JP, Horn JK, et al. Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease. Arch Surg 2010;145:28-33.
- Bansal VK, Misra MC, Garg P, Prabhu M. A prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and common bile duct stones. Surg Endosc 2010;24:1986-1989.
- Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A. Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg 2013;206:457-463.
- Bansal VK, Misra MC, Rajan K, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc 2014;28:875-885.
- Ding G, Cai W, Qin M. Single-stage vs. two-stage management for concomitant gallstones and common bile duct stones: a prospective randomized trial with long-term follow-up. J Gastrointest Surg 2014;18:947-951.
- Lee SJ, Choi IS, Moon JI, Choi YW, Ryu KH. Comparison of one-stage laparoscopic common bile duct exploration plus cholecystectomy and two-stage endoscopic sphincterotomy plus laparoscopic cholecystectomy for concomitant gallbladder and common bile duct stones in patients over 80 years old. J Minim Invasive Surg 2022;25:11-17.
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Editorial
Journal of Minimally Invasive Surgery 2022; 25(1): 7-8
Published online March 15, 2022 https://doi.org/10.7602/jmis.2022.25.1.7
Copyright © The Korean Society of Endo-Laparoscopic & Robotic Surgery.
One-stage versus two-stage approach for concomitant gallbladder and common bile duct stones: which one is more proper in patients over 80 years old?
Seung Eun Lee
Department of Surgery, Chung-Ang University College of Medicine, Seoul, Korea
Correspondence to:Seung Eun Lee
Department of Surgery, Chung-Ang University Hospital, 102 Heukseok-ro, Dongjak-gu, Seoul 06973, Korea
Tel: +82-2-6299-1545
Fax: +82-2-824-7869
E-mail: selee508@cau.ac.kr
ORCID:
https://orcid.org/0000-0003-1830-9666
This is an Open Access article distributed under the terms of the Creative Commons Attribution Non-Commercial License (http://creativecommons.org/licenses/by-nc/4.0/) which permits unrestricted non-commercial use, distribution, and reproduction in any medium, provided the original work is properly cited.
Abstract
At present, the optimal treatment for common bile duct (CBD) stones combined with gallstones is still controversial. The two most widely accepted techniques are one-stage laparoscopic CBD exploration plus laparoscopic cholecystectomy (LC) and two-stage preoperative endoscopic sphincterotomy plus LC. Considering that all current evidence comes from nonrandomized controlled trials, multicenter randomized controlled trials are needed to further establish the treatment strategy for elderly patients with CBD stones combined with gallstones.
Keywords: Gallstones, Common bile duct, Laparoscopic cholecystectomy, Endoscopic sphincterotomy
Body
Since the introduction of laparoscopic cholecystectomy (LC), the optimal treatment for common bile duct (CBD) stones combined with gallstones, a condition known as cholecysto-choledocholithiasis (CCL), remained controversial for years despite the results of several randomized controlled trials comparing one-stage laparoscopic CBD exploration (LCBDE) plus LC (LCBDE + LC) and two-stage preoperative endoscopic retrograde cholangiopancreatography with sphincterotomy plus LC (pre-ERCP + LC) [1–8]. In general, the one-stage procedure is expected to reduce the overall hospital stay and cost, albeit being highly technically demanding. Especially, elderly patients had higher incidences of cardiovascular disease and pulmonary disease, as well as higher grades of American Society of Anesthesiologists physical status classification, implying that they might have greater potential risks for laparoscopic surgery and general anesthesia than young patients. The two-stage procedure is associated with a higher CBD stone clearance and lower postoperative bile leakage, while a higher rate of pancreatitis is associated with endoscopic procedure. In addition, ERCP-caused dysfunction of the sphincter of Oddi can be permanent, leading to damage of the sphincter barrier and duodenobiliary reflux.
For elderly patients, choosing the best treatment strategy between two procedures is a more difficult process than young patients because elderly patients typically have underlying chronic diseases and age-specific deterioration of organ function. Consequently, they are classified as a high-risk group for surgery under general anesthesia. Furthermore, elderly patients are associated with high morbidity during the perioperative period, so endoscopic alternatives may be preferred. However, the risk of ERCP-associated complications also increases in elderly patients, and their cooperation can be limited due to physical or mental impairments and anatomical complexities, such as periampullary diverticula, which increase the failure rate of endoscopic procedures.
This study compared one-stage LCBDE + LC and two-stage pre-ERCP + LC for patients with CCL over 80 years of age [9]. The results showed no significant difference between these approaches in terms of treatment safety and efficacy such as postoperative morbidity and hospital stay. However, in the one-stage LCBDE + LC group, there were more patients with previous gastrectomy, multiple large (≥15 mm) CBD stones, or the inability to cooperate with endoscopic procedures. Importantly, this study indicates that the one-stage LCBDE + LC is a better treatment option for elderly patients with these conditions.
NOTES
Conflict of interest
The author has no conflicts of interest to declare.
Funding/support
None.
References
- Cuschieri A, Lezoche E, Morino M, et al. E.A.E.S. multicenter prospective randomized trial comparing two-stage vs single-stage management of patients with gallstone disease and ductal calculi. Surg Endosc 1999;13:952-957.
- Sgourakis G, Karaliotas K. Laparoscopic common bile duct exploration and cholecystectomy versus endoscopic stone extraction and laparoscopic cholecystectomy for choledocholithiasis. A prospective randomized study. Minerva Chir 2002;57:467-474.
- Noble H, Tranter S, Chesworth T, Norton S, Thompson M. A randomized, clinical trial to compare endoscopic sphincterotomy and subsequent laparoscopic cholecystectomy with primary laparoscopic bile duct exploration during cholecystectomy in higher risk patients with choledocholithiasis. J Laparoendosc Adv Surg Tech A 2009;19:713-720.
- Rogers SJ, Cello JP, Horn JK, et al. Prospective randomized trial of LC+LCBDE vs ERCP/S+LC for common bile duct stone disease. Arch Surg 2010;145:28-33.
- Bansal VK, Misra MC, Garg P, Prabhu M. A prospective randomized trial comparing two-stage versus single-stage management of patients with gallstone disease and common bile duct stones. Surg Endosc 2010;24:1986-1989.
- Koc B, Karahan S, Adas G, Tutal F, Guven H, Ozsoy A. Comparison of laparoscopic common bile duct exploration and endoscopic retrograde cholangiopancreatography plus laparoscopic cholecystectomy for choledocholithiasis: a prospective randomized study. Am J Surg 2013;206:457-463.
- Bansal VK, Misra MC, Rajan K, et al. Single-stage laparoscopic common bile duct exploration and cholecystectomy versus two-stage endoscopic stone extraction followed by laparoscopic cholecystectomy for patients with concomitant gallbladder stones and common bile duct stones: a randomized controlled trial. Surg Endosc 2014;28:875-885.
- Ding G, Cai W, Qin M. Single-stage vs. two-stage management for concomitant gallstones and common bile duct stones: a prospective randomized trial with long-term follow-up. J Gastrointest Surg 2014;18:947-951.
- Lee SJ, Choi IS, Moon JI, Choi YW, Ryu KH. Comparison of one-stage laparoscopic common bile duct exploration plus cholecystectomy and two-stage endoscopic sphincterotomy plus laparoscopic cholecystectomy for concomitant gallbladder and common bile duct stones in patients over 80 years old. J Minim Invasive Surg 2022;25:11-17.
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