C. Paterson1, B. Tracey2, D. Torres3, K. Young3, B. Hochman4, M. B. Mulder5, M. Zielinkski6, X. Luo-Owen7, D. D. Yeh5, R. B. Gelbard1 1Emory University School Of Medicine,Surgery,Atlanta, GA, USA 2Grady Memorial Hospital,Surgery,Atlanta, GA, USA 3Geisinger Medical Center,Danville, PA, USA 4Columbia University Medical Center,New York, NY, USA 5Ryder Trauma Center/Jackson Memorial Hospital,Miami, FL, USA 6Mayo Clinic,Rochester, MN, USA 7Loma Linda University Medical Center,Loma Linda, CA, USA
Introduction: There is significant heterogeneity in the diagnosis and management of suspected common bile duct (CBD) stones in patients with choledocholithiasis (CDL) or gallstone pancreatitis (GP). This study describes current trends in demographics, diagnostic modalities, and management strategies for these two disease processes.
Methods: We conducted a multicenter, prospective observational study over a 2.5-year period of adults with acute GP or CDL undergoing same-admission cholecystectomy. Data regarding demographics, comorbidities, labs, imaging, hospital course and management were collected. Categorical data were compared using χ 2 testing and are reported as frequencies.
Results:There were 989 patients included; 337 (34.1%) had GP, 586 (59.3%) had CDL, 66 (6.7%) had both GP and CDL. There was no difference in gender or race between groups. Jaundice (18.4% vs 9.7%, p=0.003), sonographic CBD stones (17.5% vs 6.0%, p<.0001), and preoperative ERCP (46.5% vs 23.3%, p<.0001) occurred more often in CDL than GP. Pre-op CT scans (50.9% vs 33.4%, p<.0001) were more common in GP than CDL. While there was no difference in the rate of intraoperative cholangiograms (IOC) performed between groups (p=0.88), CBD stones in GP were managed most often with IOC (n=145, 36.0%). However, positive IOCs were still more common in CDL than GP (14.6% vs 8.7%, p=0.007) as was the need for intraoperative and postoperative ERCPs (18.6% vs 7.7%, p<.0001). The rates of laparoscopic or robotic CCY were similar between groups, but an open procedure was more frequent in the CDL group (8.1% vs 4.5%, p=0.02). Despite more patients in the CDL group receiving pre-op antibiotics for >24 hours (44.5% vs 32.5%, p=0.002), gallbladders were noted to be more inflamed (56.9% vs 47.6%, p=0.04) and gangrenous (6.9% vs 3.2%, p=0.01) in the CDL group.
Conclusion:CDL and GP are two very distinct disease processes with different management approaches. Patients with CDL appear to require greater use of ERCP to clear the CBD and this is associated with more severe inflammatory pathology and need for open procedures. Patients with GP are more likely to be managed with laparoscopic CCY followed by IOC rather than preoperative ERCP. Further study is warranted to determine optimal diagnostic and therapeutic strategies for managing CBD stones while ensuring best possible patient outcomes in these two populations.