Biliary stenting as a bridge to cholecystectomy in patients with choledocholithiasis

Early laparoscopic cholecystectomy after endoscopic retrograde cholangiopancreatography (ERCP) is recommended for patients with choledocholithiasis to reduce the risk of recurrent biliary events (RBE). However, in clinical practice early surgery is not always feasible. The role of biliary stenting as a bridging strategy before delayed cholecystectomy remains insufficiently studied. This study evaluated outcomes of delayed cholecystectomy after ERCP with biliary stent placement compared with early surgery in a stented cohort.

We conducted a retrospective single-center study including patients who underwent ERCP with biliary stent placement followed by early cholecystectomy (≤ 14 days; eCCY) or delayed elective cholecystectomy (> 14 days; dCCY). The primary endpoint was the occurrence of RBE. Inverse probability of treatment weighting (IPTW) and sensitivity analysis were performed to address baseline imbalances. Multivariable logistic regression was performed to identify independent predictors of RBE. Incidence rates per person-time were calculated to account for differences in exposure time. Kaplan-Meier analysis assessed the temporal distribution of events. A sensitivity analysis was conducted excluding patients with acute cholecystitis at presentation.

A total of 338 patients were included (85 eCCY, 253 dCCY). Overall RBE occurred in 16.9% of patients, with no significant difference between groups (20.0 vs. 15.8%, p = 0.372). Timing of cholecystectomy was not independently associated with RBE (odds ratio 1.40, 95% confidence interval 0.71-2.76, p = 0.340). The incidence rate was 3.04 per 100 person-days in the eCCY group and 0.22 in the dCCY group, reflecting non-random treatment allocation. Intraoperative and postoperative outcomes were comparable. However, patients requiring urgent surgery due to RBE demonstrated increased operative complexity. The IPTW adjustment and sensitivity analysis confirmed all primary findings.

In selected patients undergoing ERCP with biliary stent placement, delayed cholecystectomy was safe and feasible and was not associated with worse perioperative outcomes compared with early surgery. RBE occurred predominantly in the early post-ERCP period, but overall risk was not increased by delayed surgery. Patients requiring urgent surgery represent a higher-risk subgroup.