Cholecystectomy First vs Sequential Common Bile Duct Imaging + Cholecystectomy
Cholecystectomy First vs Sequential Common Bile Duct Imaging + Cholecystectomy
The purpose of this study is to evaluate if cholecystectomy first (studied group) versus
 sequential common bile duct imaging/cholecystectomy (control group) result in a decrease of
 hospital stay, morbidity/mortality and costs in the management of patients with a suspicion
 of gallstone migration.
Emergency cholecystectomy is nowadays an accepted surgical procedure routinely performed
 worldwide. The main indications include acute cholecystitis, cholangitis and gallstone
 migration. Abnormal liver function tests upon admission and suspicion for accompanying common
 bile duct (CBD) stone can delay the surgical management due to the need for further
 investigations and/or therapeutic maneuvers. These procedures include magnetic resonance
 cholangio-pancreatography (MRCP), endoscopic ultrasound (EUS) and endoscopic retrograde
 cholangio-pancreatography (ERCP).

 While useful to detect or exclude potential CBD stones, these procedures include inherent
 risks, delay the surgical treatment, extend hospital stay and as a result, increase the
 overall medical costs. They can also potentially increase the morbidity and/or mortality by
 delaying emergency cholecystectomy (due to the presence of more local inflammation and
 adherence). Finally, more and more centers perform systematic intra-operative cholangiogram
 during cholecystectomies (laparoscopic or open), which allow an accurate assessment of the
 CBD and potentially lead to its subsequent exploration (endoscopic or surgical).

 In this study, the investigators will assess the following hypotheses:

 -  Patients with a SUSPICION of gallstone migration (with or without associated
 cholecystitis) should undergo emergency cholecystectomy with intra-operative
 cholangiogram (IOC) first

 -  "Cholecystectomy first" strategy will decrease both the length of hospital stay and the
 morbidity/mortality by decreasing the number of unnecessary EUS, MRCP and ERCP and
 therefore decreasing the overall number of their complications, as well as decreasing
 the complications related to delayed cholecystectomy (increased adherences due to
 inflammation, especially in case of associated cholecystitis, which increase the risk of
 bleeding, CBD lesion, duodenal lesion, gastric lesion, colon lesion, gallbladder
 perforation and intra-abdominal gallstones spillage with potential
Inclusion Criteria:

 -  Patients must have a clinical diagnosis of gallstone migration, defined as right upper
 quadrant or epigastric abdominal pain and abnormal liver function tests (increase of
 at least two common hepatic parameters [AST, ALT, alkaline phosphatase, gGT and/or
 bilirubin], with one of them being either AST or ALT with a value at least two times
 higher than the norm) with a reasonable exclusion of other common differential
 diagnoses

 -  Patients will be included regardless the presence of an associated cholecystitis,
 defined as right upper quadrant abdominal pain, radiological signs of cholecystitis
 (including radiological Murphy sign and/or thickened gallbladder wall and/or free
 abdominal fluid around the gallbladder) and signs of infection (including fever,
 increased CRP or white blood cell count)

 -  Age ≥ 16 years

 Exclusion Criteria:

 -  Presence of CBD stone on CT or US performed on admission (which will require ERCP
 exploration prior to surgery)

 -  Associated radiologically proven gallstone pancreatitis

 -  Associated cholangitis

 -  Medical conditions preventing surgery such as acute stroke, acute coronary syndrome,
 severe cardiac failure (NYHA class IV and/or respiratory failure with SpO2 < 85% with
 room air and/or LVEF < 35%), severe COPD with VEMS < 30 % of predicted value

 -  Medical conditions preventing informed consent

 -  Patients with contraindications to MRI (MRI-incompatible electronic devices [e.g.
 pacemakers], implants or prostheses, vascular clips less than 2 weeks, severe
 claustrophobia) and to EUS/ERCP (surgery with gastric diversion, severe cardiac
 dysfunction)