Treatment of choledocholithiasis in patients with liver cirrhosis. Surgical treatment or endoscopic sphincterotomy?

摘要

OBJECTIVE: The clinical features of choledocholithiasis were analyzed in cirrhotic patients. The outcomes of surgical treatment and endoscopic sphincterotomy (EST) in this situation were compared and the risk factors predictive of an increased mortality rate were identified. SUMMARY BACKGROUND DATA: In cirrhotic patients, high risk for gallbladder stones in cholecystectomy has been established. Common bile duct stones can often exacerbate liver dysfunction and might be more difficult to treat. METHODS: Among 16 cirrhotic patients with choledocholithiasis, 9 underwent choledocholithotomy and T-tube placement (surgery group) and 7 underwent EST (EST group). Pretreatment clinical data were comparable between groups. RESULTS: Among 16 patients, 15 had biliary tract symptoms and 7 had cholangitis. The surgery group had excessive intraoperative hemorrhage (1576 mL) and a high morbidity rate (66.7%). The mortality rate was 44.4%: 0% in Child A or B classification patients and 80% in Child C patients. The common causes of death were liver failure, postoperative hemorrhage, and sepsis. The EST group had no complications related to procedures, but there was one death (14.3%) due to preexisting liver failure. Hepatic dysfunction, coagulopathy, and cholangitis were factors predictive of an increased mortality rate. CONCLUSIONS: Choledocholithiasis in cirrhotic patients should be treated by EST after liver function and general condition are improved by medical management, except in emergency cases.