May 28, 2014
Endoscopic Procedure Does Not Reduce Disability Due To Pain Following Gallbladder Removal
In certain patients with abdominal pain after gallbladder removal (cholecystectomy), undergoing an endoscopic procedure involving the bile and pancreatic ducts did not result in fewer days with disability due to pain, compared to a placebo treatment, according to a study in the May 28 issue of JAMA.
Peter B. Cotton, M.D., F.R.C.P., F.R.C.S., of the Medical University of South Carolina, Charleston, and colleagues randomly assigned patients with pain after cholecystectomy (and with no significant laboratory or imaging abnormalities) to sphincterotomy (n = 141) or sham (placebo; n = 73) therapy, after ERCP. Success of treatment was defined as less than 6 days of disability due to pain in the prior 90 days both at months 9 and 12 after randomization, with no narcotic use and no further sphincter intervention.
The rate of successful outcome at 12 months was 37 percent for the patients assigned to sham procedure, and 23 percent for those assigned to sphincterotomy. The most common reason for failure in both treatment groups (72 percent sphincterotomy, 56 percent sham) was persistent elevation in a pain-disability score, with or without re-intervention or narcotic use.
No clinical subgroups appeared to benefit from sphincterotomy more than others. Pancreatitis occurred in 11 percent of patients after primary sphincterotomies and in 15 percent of patients in the sham group.
Of the nonrandomized patients in an observational study group, 24 percent who underwent biliary sphincterotomy, 31 percent who underwent dual sphincterotomy, and 17 percent who did not undergo sphincterotomy had successful treatment.
"These findings do not support the use of ERCP and sphincterotomy for these patients," the authors write.
"The finding that endoscopic sphincterotomy is not an effective treatment has major implications for clinical practice because it applies to many thousands of patients."