In a patient with cholecystitis and a stent (endoscopic stent) placement, should the stent be removed first or should a cholecystectomy be performed first?

Management of Cholecystitis with Biliary Stent: Sequence of Procedures

For patients with cholecystitis who have had a biliary stent placed and are scheduled to return after 6 weeks, the stent should be removed first followed by cholecystectomy during the same procedure. 1

Rationale for Stent Removal First

• Biliary stents used for treating dominant stricture or cholecystitis should be removed 1-2 weeks following insertion, with longer periods increasing risk of complications 1
• Short-term use of biliary stents followed by further endoscopy or surgery is strongly recommended by guidelines to ensure adequate biliary drainage 1
• Stents tend to clog rapidly in patients, with studies showing complications developing in up to 40% of patients during the period with stents in situ 2
• Acute cholangitis can develop secondary to a clogged biliary stent, particularly when left in place beyond the recommended timeframe 3

Procedural Approach

• The optimal approach is to first perform ERCP for stent removal, followed immediately by cholecystectomy during the same anesthetic session 1
• If same-session procedures are not feasible, stent removal should still precede cholecystectomy to:
  • Reduce risk of cholangitis from stent clogging 3
  • Allow assessment of biliary anatomy prior to surgery 1
  • Confirm adequate biliary drainage before proceeding with definitive treatment 1

Evidence Supporting Early Intervention

• Meta-analysis data shows that mortality is higher in patients with a "wait and see" approach compared to those who undergo prophylactic cholecystectomy after biliary drainage (14.1% vs 7.9%) 1
• Secondary endpoints of recurrent pain, jaundice, and cholangitis are also significantly more common in patients with delayed intervention 1
• Prophylactic cholecystectomy after common bile duct stone extraction reduces the incidence of subsequent cholecystitis 1

Complications of Delayed Stent Removal

• Stent clogging can occur as early as 1-2 months after placement, leading to recurrent cholangitis 3
• Studies show that when referring physicians do not adhere to treatment protocols for timely stent exchange, up to 70% of patients require nonelective intervention for jaundice and/or cholangitis 2
• Biliary stent placement alone without definitive treatment results in a high rate of symptom recurrence (up to 50%) 4

Special Considerations

• In high-risk surgical patients (ASA class 3-4), a more cautious approach may be warranted, but the stent should still be removed first to assess biliary drainage 1
• For patients with prohibitive surgical risk, biliary sphincterotomy and endoscopic duct clearance alone may be considered as an alternative to cholecystectomy 1
• If the patient has coagulopathy, endoscopic approaches are preferred over percutaneous methods due to lower bleeding risk 1

By removing the stent first and proceeding with cholecystectomy, you minimize the risk of stent-related complications while providing definitive treatment for cholecystitis in a timely manner.