Editorials

Endoscopic treatment of bile duct stones in elderly people

Consider cholecystectomy unless patient is unfit 

Although the standard treatment of gall bladder and bile duct stones has been surgical, postoperative morbidity and mortality increase with age and concomitant disease.¹ Peroral endoscopic techniques provide an effective alternative for removing bile duct stones by endoscopic sphincterotomy and stone extraction and may be safer than surgery in elderly people and other high risk groups as the associated morbidity and mortality are unchanged regardless of age.² As endoscopic management of bile duct stones and leaving the gall bladder in situ could be definitive treatment in these patients, there is a tendency to adopt a wait and see strategy even in those who may be fit for surgery.³ Several recent series have, however, suggested that morbidity and mortality after surgical bile duct exploration have decreased,⁴ and two recent prospective randomised studies have questioned the rationale for leaving the gall bladder in situ after endoscopic sphincterotomy. ^{5 6} Indeed, the published evidence suggests an individualised approach to the management and outcomes of bile duct and gall bladder stones in elderly and high risk patients.

Prospective randomised studies comparing bile duct clearance rates with endoscopic sphincterotomy and with open surgery showed rates of 88% versus 94%⁵ and 90% versus 90%.⁶ A prospective randomised study of endoscopic bile duct clearance versus laparoscopic bile duct exploration showed rates of 93% versus 100%.⁷ The frequency of retained bile duct stones after open surgery is about 1-5%.⁸ In 12 recent series of open surgery published from 1988 to 1992 mortality in patients aged over 70 ranged from 0 to 9%, and in eight series it was less than 4%.⁴ In comparison, complications from endoscopic sphincterotomy occur in 5-10% of cases, with a mortality of 0.5-1% unrelated to age.²

Recent prospective randomised trials comparing surgery (open and laparoscopic) with sphincterotomy for bile duct stones have found that morbidity and mortality were similar for both treatments, presumably in non-emergency situations. ^{5-7 9} In elderly or high risk patients morbidity was 23% after sphincterotomy versus 16% after surgery, with mortality 4% versus 6% respectively.⁵ In patients presenting as emergencies with acute cholangitis a prospective randomised trial found that sphincterotomy was associated with fewer complications and lower mortality than surgery.¹⁰ Thus in elderly or high risk patients elective surgery may be as safe as sphincterotomy, but this requires further evaluation. In cholangitis urgent sphincterotomy appears to be the preferred option.

What is the risk of recurrent biliary symptoms or complications after endoscopic sphincterotomy for bile duct stones if the gall bladder is left in situ? Retrospective studies of patients who have undergone endoscopic sphincterotomy for bile duct stones with gall bladders left in situ suggest that only about 10% of patients develop recurrent biliary problems over 10 years.¹¹ However, two prospective studies suggest that a higher proportion of patients develop recurrent biliary symptoms after a shorter period. ^{5 6} Targarona et al randomised elderly and other high risk patients to either endoscopic sphincterotomy with the gall bladder left in situ or open surgery and found that after a mean follow up of 17 months biliary symptoms recurred in 10 of 50 (20%) in the sphincterotomy group (7 of whom required surgery) versus 3 of 48 (6%) in the surgery group.⁵ Hammarstrom et al randomised middle aged and elderly patients with definite bile duct stones to endoscopic sphincterotomy with the gall bladder left in situ or open surgery and found that after a follow up of more than 5 years, 13 of 35 (37%) in the sphincterotomy group required surgery (though only seven of these (20%) had recurrent biliary symptoms) compared with 2 of 41 (5%) in the surgery group.⁶ In another prospective randomised study of 206 patients early surgery was required in 19% in the endoscopic group and 1.8% in the surgery group.⁹ The risk of acute cholecystitis after sphincterotomy without a cholecystectomy ranges from 1 to 16%; most of these cases tend to occur soon after the sphincterotomy in those with gall bladder stones. ^{5 8}

Thus, although 20-40% of patients may require subsequent cholecystectomy for recurrent symptoms after 17 months to 5 years, the converse is also truethat is, most (60-80%) will not require cholecystectomy. Even if cholecystectomy is delayed, the outcome may be no worse than after early cholecystectomy.³

The advantage of laparoscopic cholecystectomy in elderly patients is fewer complications, lower mortality, and a shorter length of stay than after open cholecystectomy.¹² Elderly patients have higher morbidity and length of stay after laparoscopic cholecystectomy than younger ones because elderly patients are more likely to present with acute complications of gall stones.¹³ In high risk patients laparoscopic cholecystectomy has less morbidity and mortality than open cholecystectomy.¹²

Based on current evidence we therefore suggest the following approach for managing bile duct stones with an intact gall bladder in elderly people. Sphincterotomy should be the initial procedure in acute cholangitis¹⁰ or severe gall stone pancreatitis.⁸ In an elective clinical setting, if the patient is otherwise fit, the options include: (a) endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy; (b) open or laparoscopic cholecystectomy and bile duct exploration; and (c) endoscopic retrograde cholangiopancreatography and cholecystectomy only for recurrent symptoms (wait and see strategy). The choice should be made according to local availability and expertise. If the patient is unfit with comorbid disease then leaving the gall bladder in situ is justified.

Tony C K Tham, Consultant physician and gastroenterologist. 

Department of Medicine, Ulster Hospital, Dundonald, Belfast BT16 0RH (ttham{at}sharman.dnet.co.uk)

David L Carr-Locke, Associate professor of medicine and director of endoscopy. 

Division of Gastroenterology, Brigham and Women's Hospital, Harvard Medical School, Boston, MA 02115, USA (dlcarrlock{at}bics.bwh.harvard.edu)

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