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Surgery Reduces Risk of Complications Even in High-Risk Veterans After Endoscopic Therapy for Biliary Stone Disease

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Abstract

Background

In otherwise healthy patients, randomized trials have shown reduced mortality with cholecystectomy (CCY) when compared to non-operative management after endoscopic retrograde cholangiopancreatography (ERCP) for biliary stone disease. These findings may not apply to veterans with multiple comorbidities, who have an increased risk of postoperative complications.

Aims

Our study assessed the benefit of CCY among veterans with multiple comorbidities.

Methods

Medical records of patients undergoing ERCP for biliary stone-related diseases from July 2008 to December 2016 were reviewed. Among patients who did not undergo CCY, risk of postoperative complications or death with CCY was estimated using the American College of Surgeons National Surgery Quality Improvement Program risk calculator. Charlson comorbidity index (CCI) and American Society of Anesthesiologists classification system (ASA) were used to assess patient’s functional status. The primary outcome was incidence of recurrent biliary events or death with non-operative management, compared to estimated risk of serious postoperative complications or death with CCY.

Results

A total of 152 patients met inclusion criteria, 81 of whom did not undergo CCY. Patients managed non-operatively were older and less medically fit than patients who underwent CCY. Biliary complications recurred in 23 patients managed non-operatively, including 3 deaths due to cholangitis. Among patients with CCI ≥ 3 and ASA ≥ 3 who were managed non-operatively (n = 43), the risk of serious biliary events was significantly higher than estimated risk of serious postoperative complications with laparoscopic CCY (26 vs 5%, p < 0.001).

Conclusion

Our study suggests that non-operative management is associated with a higher risk of complications than laparoscopic CCY, even among veterans with significant comorbidities.

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Abbreviations

ACS-NSQIP:

American College of Surgeons National Surgery Quality Improvement Program risk calculator

ASA:

American Society of Anesthesiologists classification system

CCI:

Charlson comorbidity index

CCY:

Cholecystectomy

ERCP:

Endoscopic retrograde cholangiopancreatography

ES:

Endoscopic sphincterotomy

SD:

Standard deviation

VA:

Veterans Affairs

VASQIP:

Veterans Affairs Surgical Quality Improvement Program

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Authors and Affiliations

  1. Division of Gastroenterology and Hepatology, Department of Medicine, Virginia Commonwealth University, MCV Box 980342, Richmond, VA, 23298-0342, USA

    Samarth S. Patel, Divyanshoo R. Kohli, Pritesh R. Mutha, Alvin Zfass & Tilak U. Shah

  2. Division of Gastroenterology, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA

    Samarth S. Patel, Divyanshoo R. Kohli, Pritesh R. Mutha, Alvin Zfass & Tilak U. Shah

  3. Department of Surgery, Hunter Holmes McGuire VA Medical Center, Richmond, VA, USA

    Jeannie Savas

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  1. Samarth S. Patel
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Correspondence to Samarth S. Patel.

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Patel, S.S., Kohli, D.R., Savas, J. et al. Surgery Reduces Risk of Complications Even in High-Risk Veterans After Endoscopic Therapy for Biliary Stone Disease. Dig Dis Sci 63, 781–786 (2018). https://doi.org/10.1007/s10620-018-4940-8

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  • DOI: https://doi.org/10.1007/s10620-018-4940-8

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