SNFGE SNFGE
 
Thématique :
- Foie
Originalité :
Intermédiaire
Solidité :
Intermédiaire
Doit faire évoluer notre pratique :
Dans certains cas
 
 
Nom du veilleur :
Professeur Jean-Marie PERON
Coup de coeur :
 
 
Gastroenterology
  2017/09  
 
  2017 Sep;153(3):762-771.e2.  
  doi: 10.1053/j.gastro.2017.05.048.  
 
  Practice Patterns for Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography for Patients With Choledocholithiasis.  
 
  Huang RJ, Barakat MT, Girotra M, Banerjee S  
  https://www.ncbi.nlm.nih.gov/pubmed/28583822  
 
 

Abstract

BACKGROUND & AIMS:

Cholecystectomy (CCY) after an episode of choledocholithiasis requiring endoscopic retrograde cholangiopancreatography (ERCP) with stone extraction reduces recurrent biliary events compared to expectant management. We studied practice patterns for performance of CCY after ERCP for choledocholithiasis using data from 3 large states and evaluated the effects of delaying CCY.

METHODS:

We conducted a retrospective cohort study using the ambulatory surgery, inpatient, and emergency department databases from the states of California (years 2009-2011), New York (2011-2013), and Florida (2012-2014). We collected data from 4516 patients hospitalized with choledocholithiasis who underwent ERCP. We compared outcomes of patients who underwent CCY at index admission (early CCY), elective CCY within 60 days of discharge (delayed CCY), or did not undergo CCY (no CCY), calculating rate of recurrent biliary events (defined as an emergency department visit or unplanned hospitalization due to symptomatic cholelithiasis, cholecystitis, choledocholithiasis, cholangitis, or biliary pancreatitis), mortality, and cost by CCY cohort. We also evaluated risk factors for not undergoing CCY. The primary outcome measure was the rate of recurrent biliary events in the 365 days after discharge from index admission.

RESULTS:

Of the patients who underwent ERCP for choledocholithiasis, 41.2% underwent early CCY, 10.9% underwent delayed CCY, and 48.0% underwent no CCY. Early CCY reduced relative risk of recurrent biliary events within 60 days by 92%, compared with delayed or no CCY (P < .001). After 60 days following discharge from index admission, patients with early CCY had an 87% lower risk of recurrent biliary events than patients with no CCY (P < .001) and patients with delayed CCY had an 88% lower risk of recurrent biliary events than patients with no CCY (P < .001). A strategy of delayed CCY performed on an outpatient basis was least costly. Performance of early CCY was inversely associated with low facility volume. Hispanic race, Asian race, Medicaid insurance, and no insurance associated inversely with performance of delayed CCY.

CONCLUSIONS:

In a retrospective analysis of >4500 patients hospitalized with choledocholithiasis, we found that CCY was not performed after ERCP for almost half of the cases. Although early and delayed CCY equally reduce the risk of subsequent recurrent biliary events, patients are at 10-fold higher risk of recurrent biliary event while waiting for a delayed CCY compared with patients who underwent early CCY. Delayed CCY is a cost-effective strategy that must be balanced against the risk of loss to follow-up, particularly among patients who are ethnic minorities or have little or no health insurance.

 

 
Question posée
 
Quand faut-il proposer une cholécystectomie dans les suites d’une CPRE pour lithiase de la VBP?
 
Question posée
 
Le plus tôt possible et si possible au cours de la même hospitalisation.
 
Commentaires

Il s’agit d’une étude rétrospective mais concernant un nombre important de patients (4516) qui ont été traités par CPRE pour une LVBP. La cholécystectectomie précoce (au cours de l’hospitalisation) diminue le risque de nouvelles complications de la maladie lithiasique et de mortalité liée à ces complications. Il diminue également la nécessité de laparotomie, et le coût est moindre.

Il suffit maintenant de convaincre nos chirugiens et nos anesthésistes.

 
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