Post-ERCP clearance of bile duct stones: should the gallbladder be left in-situ?

Endoscopic retrograde cholangiopancreatography (ERCP) has become the gold standard management for patients who present with common bile duct stone (CBDS). Although laparoscopic cholecystectomy is generally recommended for patients who have CBDS clearance, there is still a significant proportion of patients who are managed expectantly. Our study aimed to evaluate the outcomes of expectant management (EM) versus prophylactic cholecystectomy after initial endoscopic removal of CBDS.

We performed a retrospective review of all patients who underwent ERCP for choledocholithiasis from 1st January 2017 to 31st December 2019. Patients were further classified into young or elderly group using age 60 years as the cut-off. Primary outcomes measured biliary-related complications in each interventional group whereas secondary outcomes measured all-cause mortality.

136 patients (51.3%) had EM whereas 129 patients (48.7%) were initially planned for LC. There was 20.6% of recurrence of biliary events in EM group as compared to 3.9% in LC group. The median time from first ERCP to recurrence of biliary events in the EM group was 14 months. Overall complications of LC group was low (5.4%) with nil operative-related mortality. However, there was a significant higher proportion of elderly patients in EM group in comparison to LC group (88.2% vs 31%) and 51.4% of EM group died during follow-up period with only one biliary-related death.

Prophylactic cholecystectomy should be recommended for patients who have undergone ERCP clearance of CBDS. A watch-and-wait approach may be justified for elderly populations who are not ideal surgical candidates and a follow-up duration of up to 2 years is recommended.