D. Dolan1, J. Aalberg1, C. Divino1, S. Nguyen1 1Mount Sinai School Of Medicine,Surgery,New York, NY, USA
Introduction: The current standard of care for choledocholithiasis and related conditions is endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy (CCY) in the same admission. But we think that high risk patients, especially the elderly with multiple conditions, can be treated with ERCP only and avoid surgery. Surgery carries a significantly higher risk of mortality and morbidity in patients already under significant medical burden. If this group can be managed with ERCP only then the risks of CCY can be avoided. This study will hopefully show surgeons that they have another option in the management of high risk patients.
Methods: The records of a single, high volume, institution were evaluated for January 1, 2001 to December 21, 3016. Screening was done by ERCP, CCY, and timing of them. 1435 patients met criteria. Data was reviewed for days between ERCP and CCY if both done, initial admission data, baseline clinical factors, and readmission data. High risk patients were defined as over 65 years, two or more significant organ system conditions, over 65 with a single significant organ system condition, or ASA class III or above. Significant condition was defined as requiring prior operation or procedure, requiring device implant, continuous medication delivery, prior cancer, or requiring previous admission for treatment. Two groups were created; patients with ERCP only and patients with ERCP then CCY. The two groups were then case-control matched.
Results: Early data review of the ERCP then CCY group shows 79 patients with sufficient data for analysis. For that group, regardless of if procedures were done in the same admission, median time between procedures was 4 days (mean: 36.6 days, range: 1 day to 855 days). For the 33 patients who didn’t have both procedures done in the same admission the median time between procedures was 26 days (mean: 83 days, range:1 day to 855 days). 38 patients were readmitted with 30 readmitted for biliary disease and 22 of those patients admitted for interval CCY. Further analysis will generate the remaining data of the ERCP with CCY group and the ERCP alone group to allow for comparison between the two groups.
Conclusion: It is too early to draw final conclusions from our data. However, we believe the data will show that in high risk populations the standard of care can be changed. 5 patients who had an ERCP only and were later readmitted for CCY had their CCY done over 180 days later. 3 of the 5 readmissions were for their CCY. The other readmissions were for aortic valvuloplasty and choledocholithiasis pain without intervention necessary. This demonstrates the potential that these patients could have been managed with ERCP alone as only one patient demonstrated biliary symptoms requiring admission. For high risk patients this could be a lifesaving option by avoiding major surgery. We believe further data analysis will be hopeful and that our hypothesis will be proved.