Should we explore CBD during cholecystectomy in a patient undergone successful ERCP clearance of stones? a new...

Stones with CBD are often treated using endoscopic retrograde cholangiopancreatography (ERCP); nevertheless, residual or recurrent stones can arise in 5-20% of patients, which calls for thorough intraoperative examination during cholecystectomy. In order to guide selected intraoperative CBD exploration and enhance outcomes, this study examines the incidence and preoperative predictors of recurrent CBD stones in patients having cholecystectomy post-successful ERCP in patients with a high risk of stone remigration when the size of stones is less than the diameter of the cystic duct to decrease the cost of preoperative imaging and the cost of doing another ERCP that also doesn't eliminate the risk of remigration of stones. A cross-sectional study was conducted at Assiut and Aswan University Hospitals (Egypt) from August 2018 to August 2024, including 583 patients (61.9% female, mean age 48.2 ± 13.1 years) scheduled for cholecystectomy (open or laparoscopic) after ERCP for CBD stone extraction. Age ≥ 18 years, confirmed CBD stones treated by successful ERCP, and a scheduled cholecystectomy within six months were requirements for inclusion. Abdominal ultrasonography, liver function tests (LFTs), and clinical examination were all part of the preoperative evaluation. The detection of recurring stones by intraoperative choledochoscopy. Predictors of stones were found using multivariable logistic regression, with outcomes including length of hospital stay and intraoperative/postoperative issues. Intraoperative choledochoscopy identified remigrated CBD stones in 23% of patients (134/583) within three months following ERCP. A shorter ERCP-to-cholecystectomy interval (OR = 0.9 per 10 days, 95% CI: 0.85-0.95), higher direct bilirubin (OR = 1.75 per mg/dL, 95% CI: 1.2-3.0), higher alkaline phosphatase (OR = 1.75 per 100 U/L, 95% CI: 1.2-2.5), persistent jaundice (OR = 9.0, 95% CI: 5.0-15.0), and CBD dilatation ≥ 8 mm (OR = 3.5, 95% CI: 2.0-6.0) were independent predictors. Longer hospital admissions (4 vs. 3 days, p < 0.001), higher postoperative complication rates (14.9% vs. 6.5%, p = 0.004), and longer operative times (95 vs. 78 min, p < 0.001) were all observed in patients with stones. After ERCP, 23% of patients had recurrent CBD stones. When remigration is inevitable as recommended by the data of pre-ERCP MRI, we consider that an initial successful ERCP is not a definitive management and remigration is a dynamic process that can occur at any step from immediately post-successful ERCP to at any time intraoperatively during cholecystectomy. This raises a debate about the utility of preoperative imaging that cannot rule out remigration that can happen even intraoperatively during cholecystectomy. Shorter ERCP-to-cholecystectomy intervals, increased LFTs, persistent jaundice, and CBD dilatation are important predictors. Choledochoscopy-assisted selective intraoperative CBD exploration can lower postoperative morbidity in high-risk patients and decrease the total cost of sophisticated preoperative imaging or another ERCP, as it will be diagnostic and therapeutic at the same time.