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Original Investigation |

Natural Course vs Interventions to Clear Common Bile Duct Stones Data From the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks)

Mats Möller, MD1,2; Ulf Gustafsson, MD, PhD1,2; Finn Rasmussen, MD, PhD3; Gunnar Persson, MD, PhD4; Anders Thorell, MD, PhD1,2
[+] Author Affiliations
1Department of Surgery, Ersta Hospital, Stockholm, Sweden
2Department of Clinical Sciences, Karolinska Institutet, Danderyds Hospital, Stockholm, Sweden
3Department of Public Health Sciences, Karolinska Institutet, Stockholm, Sweden
4Department of Surgery, Ryhov Hospital, Jönköping, Sweden
JAMA Surg. 2014;149(10):1008-1013. doi:10.1001/jamasurg.2014.249.
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Importance  The optimal strategy for common bile duct stones (CBDSs) encountered during cholecystectomy is yet to be determined.

Objective  To evaluate the outcomes after various interventional techniques to clear the bile ducts and the natural course of CBDSs found during intraoperative cholangiography.

Design, Setting, and Participants  In a large retrospective cohort analysis, we analyzed data from the Swedish Registry for Gallstone Surgery and Endoscopic Retrograde Cholangiopancreatography (GallRiks). We included all patients with CBDSs found on intraoperative cholangiography during cholecystectomy from May 1, 2005, through December 31, 2009.

Exposures  Presence of CBDSs on intraoperative cholangiography.

Main Outcomes and Measures  Relation between strategies for handling CBDSs in terms of complication rates and/or incomplete clearance with need of intervention (ie, unfavorable outcomes).

Results  In 38 864 cholecystectomies, CBDSs were found in 3969 patients, of whom 3828 underwent analysis. Earlier or ongoing symptoms were more common with increasing stone size (P < .001). In total, postoperative unfavorable outcomes were found in 14.9% but less frequently for patients with smaller stones (P < .01). Among patients in whom no intraoperative measures were taken (representing natural course), the risk for unfavorable outcomes was 25.3%. This risk was significantly lower in patients in whom any measure was taken to clear the ducts (12.7%; odds ratio, 0.44 [95% CI, 0.35-0.55]). The same was found when small (<4 mm) and medium (4-8 mm) stones were analyzed separately (odds ratio, 0.52 [95% CI, 0.34-0.79] and 0.24 [95% CI, 0.17-0.32], respectively).

Conclusions and Relevance  The high rates of unfavorable outcomes associated with taking no measures when CBDSs are found during cholecystectomy suggest that the natural course might not be as favorable as earlier suggested. This finding implies that, in general, efforts should be made to clear the bile ducts.

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