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“The destiny of stone”▸

Clearance of bile duct stones is now possible in the majority of patients but how should residual gall bladder stones be managed in the elderly population following duct clearance? Do the risks of laparoscopic surgery outweigh those of retaining the gall bladder or is expectant management more likely to result in complications? This study randomised 178 Chinese patients over the age of 60 years to receive either early laparoscopic cholecystectomy following endoscopic sphincterotomy or expectant management. The primary outcome was further biliary complications, and secondary outcome measures were adverse events after cholecystectomy and late deaths from all causes. Nine per cent of the laparoscopic cholecystectomy patients did not undergo the procedure and conversion to open surgery was needed in 20% of surgical patients. Postoperative complications occurred in 9% of cases. Median follow up was five years. In the cholecystectomy group, 7% returned with further biliary events versus 24% among those with intact gallbladders (cholangitis in 13, acute cholecystitis in five, and biliary pain in two; p = 0.001). Late deaths were similar. Although patients with common bile duct stones are more likely to need open surgery when undergoing cholecystectomy, the authors …

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