Nationwide study of the treatment of common bile duct stones in Sweden between 1965 and 2009.

BACKGROUND: Treatment of common bile duct stones has changed. Open surgery has gradually been replaced by endoscopic and laparoscopic procedures. The aims of this study were to see how common bile duct stones have been treated in Sweden, to establish whether there were differences in morbidity and mortality between these approaches, and to identify factors influencing mortality.
METHODS: All persons undergoing inpatient common bile duct exploration or endoscopic retrograde cholangiopancreatography (ERCP) during 1965-2009 in the Swedish Hospital Discharge Registry, but without a diagnosis of malignancy in the Swedish Cancer Registry, were included. The outcome death was identified by cross-linkage to the Causes of Death Registry. Registry data on possible risk factors for mortality were collected.
RESULTS: A total of 126 885 procedures were performed in 110 119 patients. Open surgery was initially the only available method, but during the 1990s ERCP became predominant. Later, laparoscopic bile duct clearance became an established but uncommon method. A 90-day mortality rate of 0·2 per cent after open surgery, 0·8 per cent after ERCP, 0 per cent after laparoscopic exploration and 0·7 per cent after combined procedures was recorded. After adjustment for confounding, there was no difference in mortality between open surgery and ERCP. Biliary reintervention within 90 days was identified as a risk factor for death, whereas a concomitant diagnosis of pancreatitis reduced the risk.
CONCLUSION: The laparoscopic technique had the lowest mortality and morbidity rates. After adjustment for confounding factors, there was no difference in mortality after open surgery and ERCP. The favourable outcome for laparoscopy may have been due to selection bias, owing to treatment of younger, healthier subjects with less severe disease.