2 Research recommendations

The Guideline Development Group has made the following recommendations for research, based on its review of evidence, to improve NICE guidance and patient care in the future.

2.1 Diagnosing gallstone disease

What are the long‑term benefits and harms, and cost effectiveness of endoscopic ultrasound (EUS) compared with magnetic resonance cholangiopancreatography (MRCP) in adults with suspected common bile duct stones?

Why this is important

MRCP and EUS have both been found to be sufficiently accurate for diagnosing common bile duct stones, with EUS regarded as the most accurate test. MRCP is non‑invasive and so carries negligible risks to the patient. However, EUS carries a small but significant risk of patient harms, including death. There is insufficient evidence available to determine whether the benefits of improved diagnosis associated with EUS outweigh its procedural risks. Therefore, research is needed to compare MRCP with EUS to evaluate the subsequent management of common bile duct stones.

2.2 Managing gallbladder stones

What are the benefits and harms, and cost effectiveness of routine intraoperative cholangiography in people with low to intermediate risk of common bile duct stones?

Why this is important

In the evidence reviewed for this guideline, there was a lack of randomised controlled trials of intraoperative cholangiography, and the evidence that was available did not support the knowledge and experience of the Guideline Development Group. Therefore, there is a need for large, high‑quality trials to address clinical questions about the benefits and harms of intraoperative cholangiography.

2.3 Managing common bile duct stones

What models of service delivery enable intraoperative endoscopic retrograde cholangiopancreatography (ERCP) for bile duct clearance to be delivered within the NHS? What are the costs and benefits of different models of service delivery?

Why this is important

Evidence reviewed for this guideline identified that intraoperative ERCP is both clinically and cost effective, but it is unclear whether delivery of this intervention is feasible in the NHS because of the way current services are organised. It is also unclear whether intraoperative ERCP will remain cost effective if services are reorganised.

2.4 Timing of laparoscopic cholecystectomy

In adults with common bile duct stones, should laparoscopic cholecystectomy be performed early (within 2 weeks of bile duct clearance), or should it be delayed (until 6 weeks after bile duct clearance)?

Why this is important

There is a lack of evidence from randomised controlled trials of early compared with delayed laparoscopic cholecystectomy after bile duct clearance with ERCP. It is unclear what effect the timing of laparoscopic cholecystectomy has on clinical outcomes and resource use.

2.5 Information for patients and carers

What is the long‑term effect of laparoscopic cholecystectomy on outcomes that are important to patients?

Why this is important

There is a lack of information on the long‑term impact of cholecystectomy on patient outcomes. Many patients report a continuation of symptoms or the onset of new symptoms after laparoscopic cholecystectomy, and these affect quality of life. Research is needed to establish the long‑term patient benefits and harms, so that appropriate information can be provided to patients to aid decision‑making and long‑term management of their condition.

  • National Institute for Health and Care Excellence (NICE)