Upfront laparoscopic cholecystectomy versus preoperative MRCP or ERCP in patients with suspected choledocholithiasis

The optimal diagnostic and therapeutic strategy for patients with intermediate-to-high-risk of choledocholithiasis and stable or decreasing total bilirubin levels remains unclear. Although magnetic resonance cholangiopancreatography (MRCP) and endoscopic retrograde cholangiopancreatography (ERCP) are used preoperatively, their diagnostic yield, complication risks, and cost-effectiveness in this subgroup remain debated.

This retrospective cohort study included patients who underwent laparoscopic cholecystectomy (LC) for suspected choledocholithiasis between January 2018 and December 2023. Inclusion criteria were a total bilirubin between 30 and 70 µmol/L (1.8-4.1 mg/dL) at presentation with a stable or decreasing trend, or a dilated common bile duct on imaging. Patients were categorized by initial management strategy: MRCP-first, ERCP-first, upfront LC, or LC with intraoperative cholangiogram (LC-IOC). The primary outcome was diagnostic yield. Secondary outcomes included ERCP complications, hospital length of stay (LOS), and readmission rates. A cost analysis was also performed.

Of the 245 included patients, 88 were in the MRCP-first group, 35 in the ERCP-first group, 119 underwent upfront LC, and 3 had LC-IOC. Diagnostic yield was 30.7% for MRCP and 51.4% for ERCP. ERCP-related complications occurred in 17.9% of patients, including pancreatitis (8.9%), bleeding (7.1%), and perforation (1.8%). Retained CBD stones requiring postoperative ERCP occurred in 5.9% of upfront LC patients. Median LOS was shorter in the upfront LC group (3 days) compared with both the MRCP-first and ERCP-first groups (5 days each, p < 0.001). Thirty-day and 90-day readmission rates did not differ significantly across groups. The upfront LC group incurred lower hospital costs than all other groups (p < 0.001).

In intermediate-to-high-risk patients with stable or decreasing bilirubin levels, upfront LC was associated with favorable outcomes, shorter hospitalization, and lower costs. Given the modest diagnostic yield of MRCP and ERCP, these findings highlight limitations of current risk stratification and suggest the need for more selective preoperative imaging in appropriately chosen patients.