Initial cholecystectomy vs. sequential common duct endoscopic assessment and subsequent cholecystectomy for suspected gallstone migration.

Background: Guidelines recommend ERCP or EUS prior to cholecystectomy in patients with high risk for bile duct stones. (cholangitis, jaundice, visible CBD stone) In patients with low risk for CBD stone (uncomplicated gallstone pancreatitis) proceeding directly to cholecystectomy is recommended. Moderate risk patients fall into a gray area.

Design: In a recent randomized controlled trial published in JAMA  100 pts were randomized to a cholecystectomy with intraoperative cholangiography (IOPC) followed by ERCP if CBD stones were visualized or pre op EUS (followed by ERCP if CBD stones were visualized) followed by cholecystectomy. They were all moderate risk patients (abdominal pain or acute cholecystitis, elevated LFTs, gallstones on US)

Results: Compared with the preop EUS the direct cholecystectomy group had a shorter hospital stay, required less procedures, had a similar complication rate and quality of life, no deaths. 20% in each group had choledocholithiasis.