[Usefulness of endoscopic cholangiography and sphincterotomy in patients with biliary lithiasis]

With the popularity of laparoscopic cholecystectomy (LC), the algorithm of endoscopic retrograde cholangiography (ERC) with biliary sphincterotomy followed by laparoscopic cholecystectomy has proven to be an effective treatment in choledocholithiasis in symptomatic gallstone disease. However, its use as a standard approach remains controversial.

1. To determine the diagnostic and therapeutic usefulness of ERC with biliary sphincterotomy in patients with LC. 2. To evaluate clinical, biochemical and ultrasonographic factors which can be used as predictors of choledocholithiasis in symptomatic gallstone disease.

It is a retrospective study which included patients with: 1. symptomatic cholelithiasis with presurgical clinical, biochemical and ultrasonographic suspicion of choledocholithiasis; 2. patients with acute biliary pancreatitis subjected to ERC before LC; 3. patients subjected to ERC under suspicion of residual choledocholitiasis or complicated LC. The clinical laboratorial, ultrasonographic, ERC and surgical variables were analyzed.

From January 1997 to December 2001, 805 LC were performed, 91 patients were included in the final analysis. Jaundice was found at arrival in 54 patients (59%), 15 (16%) had cholangitis and 32 (35%) had pancreatitis. The ultrasonographic features found common bile duct dilation in 34 patients (38%) and choledocholithiasis in seven (7.8%). Presurgical ERC was performed in 73 patients (80.2%) and post surgically in 18 (19.8%), no intraoperative cholangiogram was performed during surgery. In the presurgical ERC, choledocholithiasis was found in 37 patients (51%) and post surgically in 8 (44%). Five biliary leaks were diagnosed during post surgical ERC, or which the cystic duct fistula was the most common. The duration of hospital stay ranged between 1 to 53 days (medium 4.8 days) after LC. The multivariate analysis showed that the best predictors of choledocholithiasis were cholangitis (OR 15.9, IC 95% 1.8-135.1 and p = 9.01) and elevated alanine aminotransferase (OR 4.7, IC 95% 1.5-15.3 and p = 0.009).

The ERC with biliary sphincterotomy and stones extraction is a useful and safe treatment of choledocholithiasis associated with symptomatic gallstone disease before or after LC. The best predictors of choledocholithiasis in ERC were cholangitis and elevation of alanine aminotransferase at arrival. It is convenient to perform ERC with biliary sphincterotomy before LC in patients with evidence of choledocholithiasis.