Treatment of choice for choledocholithiasis in patients with acute obstructive suppurative cholangitis and liver cirrhosis

To identify the treatment of choice for choledocholithiasis in patients with versus without acute obstructive suppurative cholangitis (AOSC) or liver cirrhosis, the outcomes of surgical treatment and endoscopic sphincterotomy (EST) were compared. Three hundred sixty-two consecutive patients with choledocholithiasis were divided into three groups: 27 with AOSC (Group 1), 12 with cirrhosis (Group 2), and 323 with neither AOSC nor cirrhosis (Group 3). Seventeen patients (63%) in Group 1 underwent emergent treatment, and 3 of them died. Two were treated by emergent surgery and both died; only 1 (7%) of 15 treated by emergent EST died. For all patients with AOSC, morbidity and mortality rates were 67% and 33% with surgery, and 24% and 5% with EST. In Group 2, 2 patients with Child C cirrhosis died after elective EST. One patient in Group 3 died. Mortality rates were significantly higher in Group 1 (11%) and Group 2 (17%) than in Group 3 (0.3%). Although comparisons between the two treatment approaches did not achieve statistical significance, EST had lower morbidity rates than surgery in both Group 1 (24% versus 67%) and Group 2 (22% versus 67%). The required hospital stay was half as long with EST as with surgery. EST is the recommended treatment for patients with choledocholithiasis associated with AOSC or liver cirrhosis.