Prospective evaluation of a minimally invasive approach for treatment of bile-duct calculi in the high-risk patient

Background: The best approach to bile duct stones in high-risk patients is controversial. We showed in a randomized trial that open surgery had a morbi-mortality similar to that of endoscopic sphincterotomy alone (ES) and less late biliary complications. The aim of this study was to evaluate a minimally invasive approach to duct stones in high-risk patients compared with open surgery or ES alone. Methods: Sixty high-risk patients (mean age 80 years) suspected of duct stones were treated by ES + laparoscopic cholecystectomy (LC). High-risk factors were: age > 70 years, Goldman cardiac index > 13, chronic pulmonary disease, liver cirrhosis, neurologic deficit, and severe obesity. Results: ERCP success was 87%. Duct stones were found in 75%. LC succeeded in 92%. Post-LC stay was 4 days. Overall morbidity was 19% and mortality was 3%. Recurrent symptoms (mean follow-up: 9 months) was 3.6%. When compared with open surgery or ES alone, ES + LC had a similar morbi-mortality, but shorter postop stay ( p < 0.001). Late symptoms appeared in 20% after ES alone vs 4% after open surgery or ES plus LC ( p < 0.04). Conclusions: Combined ES + LC is an effective alternative to open surgery or ES alone for treatment of duct stones in high-risk patients.