A. C. Cioci1, E. M. Urrechaga1, K. Abdul Jawad1, H. J. Quiroz1, K. D. Rakoczy2, Y. M. Rodriguez2, L. R. Barda1, G. D. Pust1, R. Rattan1, E. Q. Ginzburg1, N. Namias1, D. D. Yeh1, R. B. Gelbard3 1University Of Miami,DeWitt-Daughtry Family Department Of Surgery Divison Of Trauma, Critical Care, And Burns,Miami, FL, USA 2University Of Miami,Miller School Of Medicine,Miami, FL, USA 3University Of Alabama at Birmingham,Department Of Surgery, Division Of Trauma/Critical Care,Birmingham, Alabama, USA
Introduction:
The optimal workup and management of a patient with suspected common bile duct stones remains controversial. The purpose of this study was to compare outcomes between patients undergoing magnetic resonance cholangiopancreatography (MRCP), endoscopic retrograde cholangiopancreatography (ERCP), and cholecystectomy (CCY) ± intraoperative cholangiogram (IOC).
Methods:
We performed a post-hoc analysis of a multicenter, prospective study of patients with suspected common bile duct stones from 2016-2019. Patients were grouped according to initial study/treatment (MRCP vs ERCP vs CCY±IOC). Pairwise propensity score matching was performed to control for probability of retained common bile duct (CBD) stones. Clinical factors, management strategies, and outcomes, which included a composite endpoint (30-day readmission, any Clavien-Dindo complication, and mortality), were compared between matched groups.
Results:
Of the 989 subjects included for analysis, 308 (31%) underwent MRCP, 261 (27%) underwent ERCP, and 420 (42%) were taken for CCY without further pre-operative assessment. IOC was performed in 253 (60%) of CCY subjects. Total bilirubin (mg/dl) was significantly higher in ERCP (2.8 [1.7-4.6]) compared to MRCP (2.2 [1.2-3.6]) or CCY subjects (1.3 [0.7-2.4], p<0.001). CBD diameter (cm) was similar between ERCP (0.9±0.2) and MRCP (0.9±0.3) but was significantly lower in those proceeding directly to CCY (0.8±0.3, p<.001). Propensity scores were generated and 1:1 matching was performed to create three pairwise matched cohorts: MRCP vs ERCP (n=430), MRCP vs CCY (n=528), and ERCP vs CCY (n=430). The presence of CBD stones was significantly higher in ERCP compared to MRCP (83% vs 42%, p<0.001) or CCY subjects (83% vs 29%, p<.001). Post-operative ERCP was performed more frequently in CCY compared to MRCP (22% vs 6%, p<.001) or ERCP subjects (23% vs 2%, p<.001). The rate of retained CBD stones, as determined by the presence of stones on post-operative ERCP, was higher for CCY compared to MRCP (18% vs 6%, p<0.001) or ERCP subjects (20% vs 2%, p<.001), and in MRCP compared to ERCP subjects (6% vs 2%, p=.04). The incidence of the composite endpoint was significantly higher in CCY compared to both MRCP (37% vs 26%, p=.01) and ERCP subjects (38% vs 17%, p<.001); there was no significant difference in this composite endpoint between MRCP and ERCP (25% vs 17%, p=.08).
Conclusion:
In modern clinical practice in the United States, proceeding directly to cholecystectomy ± intraoperative cholangiogram in patients with suspected common bile duct stones is common. However, the incidence of retained CBD stones is 20% and post-operative ERCP is commonly required. Compared to ERCP and MRCP, CCY (IOC) is least successful at detecting and clearing CBD stones and is associated with overall worse outcomes at 30 days.