This meta-analysis identified that patients undergoing CBD clearance followed by prophylactic cholecystectomy had a significant reduction in biliary events, biliary pain and pancreatitis.

While patients in the community may be asymptomatic with silent CBD stones, those who present to hospital are often sick with potential sepsis, pancreatitis or obstructive jaundice. This is a disease process which is frequently fuelled by the persistent presence of cholecystolithiasis. The surgical community recognises that patients with asymptomatic cholelithiasis probably do not benefit from prophylactic cholecystectomy, but the current cohort of patients studied were symptomatic presenting with complicated CBD calculus disease.

There is significant variation in current practice in performing cholecystectomy in symptomatic patients with CBD stones and the definition of early cholecystectomy which, as reported by Nakai, can vary between studies from a mean of 8 days to up to 90 days [7]. Further, the reported cholecystectomy after ERCP for choledocholithiasis is only 22% and 8% in patients aged ≥ 75 years and ≥ 85 years, respectively [30]. A reason for this could be the comorbidity burden or frailty of the elderly patients. However, the age factor alone might also influence the surgical decision. With the increase in the elderly population worldwide and the concomitant CBD stones seen in patients with biliary calculus disease [33], an active approach is recommended even in this patient population if no absolute contraindication to anaesthesia or surgery exists. Ignoring the potential problems of CBD stones may be foolish as Hakuta and colleagues identified biliary complications, related to asymptomatic CBD stones picked up on incidental imaging, with a detection rate of 6.1% at 1 year, 11% at 3 years and 17% at 5 years [34]. Möller et al. found that among patients where no measures were taken intraoperatively or planned postoperatively, the possibility for adverse outcomes varied between 15.9 and 36.9% depending on stone size in a cohort of patients diagnosed with CBD stones using IOC [35].

There has been a paradigm shift in the management of acute biliary presentations in the last decade with increasing use of index or same admission cholecystectomy [36].

Concerns have been expressed about the risk of biliary injury with early surgery, but this remains unproven, overshadowed by the increasing concern about readmission and recurrent pancreatitis in the untreated cholecystitis patient [37]. Patients presenting with acute cholecystitis have a significant increased risk of CBD stones (10%), more than three times that seen in elective cholecystectomy. In these acute situations with sepsis, there is universal support for CBD clearance to facilitate sepsis control. What is more challenging is the decision of whether to remove the gallbladder or defer cholecystectomy in patients with CBD stones. While index admission cholecystectomy is increasingly advocated, it is not suitable for all patients and, in high-risk patients, it may be associated with adverse outcomes [37]. Mytton et al. suggest in their national cohort analysis in the UK that incentive to increase the number of index admission cholecystectomies may result in the risk of overtreating patients with cholecystitis [38]. While their study did not evaluate those who had CBD stones or clearance, one should always be cautious about the risk of overtreatment and a tailored risk assessment to prophylactic cholecystectomy should be undertaken [38]. A real-world clinical management challenge is to determine the relative contribution of cholecystitis versus cholestasis to obstructing CBD stones. Imaging may help predict the degree of cholecystitis, but it can be difficult to determine whether the dilatation/oedema is purely due to an obstructive rather than an infective element. As liver function tests become increasingly abnormal, there is a greater likelihood that the key process is CBD obstruction rather than cholecystitis. Failure to remove a septic gallbladder will increase mortality. Current preoperative grading systems offer some help, but have significant limitations [39]. Many scoring systems require surgery and thus are not useful in this situation [40].

Escourrou suggested, in 1984, that deferral of cholecystectomy in patients undergoing ERCP with endoscopic sphincterotomy (ES) was possible [41].

In a large study with a follow-up of 24.2 (< 1–82.3) months, Archibald found that cholecystectomy was eventually required in 46 (24.7%) of the deferred cholecystectomy (DC) patients on average 6 months after ES [22]. The younger subgroup underwent eventual cholecystectomy (57.6 v. 69.4 years; p < 0.001), had a lower ASA score (ASA score of 1.98 v. 2.26; p = 0.015) and had a higher chance of residual cholecystolithiasis than those with uneventful deferral. There was a higher occurrence of recurrent pancreatitis in the deferred cholecystectomy group (30%) compared to 4.8% in the prophylactic cholecystectomy [22]. Costi and colleagues, in their small study of octogenarian patients, referred to undergo LC post-ES and CBD clearance, found that while a wait-and-see policy allowed two-thirds to avoid surgery, biliary-related events developed for every second patient, often requiring surgery with eventual poorer outcomes, with 48% developing recurrent symptoms or complications [41]. A key to determining the need for post-ERCP cholecystectomy is the presence of residual cholelithiasis in the gallbladder, especially in patients with previous pancreatitis. In their retrospective study of over 160 patients post-CBD stone removal, Cui found that the incidence of acute cholecystitis was 13.6% compared to 2.5% in those without stones [24].

Physicians must weigh up the risks of complications if the gallbladder is left in situ against the risks associated with laparoscopic cholecystectomy after ERCP. Patients with ERCP clearance prior to cholecystectomy pose more technical operative difficulties leading to conversion rates of up to 20%, as reported by Lau et al. [28].

The amount of elderly patients presenting with gallstone disease is constantly rising and patients aged 80–89 years now account for 28% of male and 42% of female patients presenting with cholecystitis [43–45]. Elderly patients have increased comorbidities, reduced functional reserve and operating on elderly patients is associated with a higher risk of complications, higher conversion rates and a longer hospital stay [46]. In patients with acute cholecystitis, alternative strategies may include antibiotic management and percutaneous catheter drainage. However, a recent randomised controlled trial comparing percutaneous catheter drainage and laparoscopic cholecystectomy for high-risk patients with acute cholecystitis identified laparoscopic cholecystectomy to be associated with significantly lower rates of major complications and reinterventions [47].

Sousa, in a retrospective study of 131 patients (47 of whom were excluded for lack of data) with a mean age of 82 years, found a post-ERCP complication rate of 13% (8 pancreatitis, 6 cholangitis and 1 perforation) and a mortality rate of 0.7% in all patients. The same study found that 22% of patients had a cholecystectomy performed after ERCP with a median time to surgery of 209 days with a complication rate of 13% (1 empyema, 1 hemoperitoneum and 1 hypovolemic shock) and the mortality rate was 7%. Follow-up in this study revealed a new biliary event occurred in 20% of patients – 11% new ERCP, 9% cholecystitis, 9% cholangitis and 2% pancreatitis. Fewer biliary events were reported in patients who had a cholecystectomy (7% vs. 24%). No statistically significant difference in all-cause mortality (14% vs. 27%) or in mortality following biliary events (0% vs. 9%) [30]. However, it is important to highlight that in this meta-analysis the granular data on the cause and time of death was not readily available for analysis. Based on the risk of complications when deferring post-ERCP cholecystectomy, surgery should be offered to even elderly if no absolute contraindication to anaesthesia or surgery exists.

In their recent meta-analysis, McCarty found that patients with in situ gallbladders post-ES after ERCP for choledocholithiasis were found to have a 2.5-fold mortality rate and they highlighted that recurrent CBD stones occur in 37% of patients despite initial ERCP clearance [17]. Today, divergent views on the optimum CBD clearance technique exists. A recent meta-analysis by Ishii and colleagues, which compares BD and ES, identified that from collected data from the five RCTs and five NRCTs, the rate of complete CBD stone removal for the first session had a better outcome for endoscopic sphincterotomy followed by large balloon dilatation compared to endoscopic sphincterotomy (OR = 0.38, 95% CI 0.27–0.53, p < 0.01, I² = 57%). They found that BD increased post-procedure pancreatitis but was also accompanied by less bleeding [48]