One-stage laparoscopic procedure versus two-stage procedure in the management of common bile duct stones in patients aged 75 and more

Introduction: The management strategy for common bite duct stones (CBD) in patients over 75 years is a real challenge that requires balancing the efficacy of a multiplicity of procedures against their own morbidity. The objective is to compare one-stage surgical treatment versus the two-stage combination of endoscopy and surgery in terms of efficacy of clearing the CBD of stones and the morbidity and mortality in elderly patients. Material and methods: This study included eighty-two patients over 75 years of age with symptomatic CBD stones who presented between 2010 and 2017. Patients were treated either by one-stage surgery alone (S group, n=40) or by sequential endoscopy and surgery (ES group, n = 42). Results: Immediate and 30-day mortality, morbidity and duration of hospitalization were comparable. The failure rate for clearing CBD lithiasis was significantly higher in the ES group (26.2% vs. 7.5%, P=0.038, 95% CI). In multivariate analysis, two-stage treatment and multiple CBD stones were associated with a significantly higher risk of failure. Fewer anesthetic procedures were needed in the S group. Twelve patients (14.4%) had multiple stones packing the CBD (> 3 stones); four were treated with choledocho-duodenal anastomosis and eight with endoscopic sphincterotomy and stone removal with 100% and 50% efficacy, respectively. Conclusion: The "surgery atone" attitude compared to 2-stage endoscopic and surgical management is associated with better efficacy in terms of clearing the CBD of lithiasis and requires fewer anesthetic procedures in elderly subjects while being comparable in terms of morbidity and mortality. In patients whose CBD is packed with multiple stones, choledocho-duodenal anastomosis is an alternative to endoscopy for management of choledochotithiasis. (C) 2019 Elsevier Masson SAS. All rights reserved.