Preoperative difficulty assessment of laparoscopic cholecystectomy after treatment for choledocholithiasis

Laparoscopic cholecystectomy (LC) after endoscopic retrograde cholangiopancreatography (ERCP) has been associated with increased operative difficulty; however, the optimal timing of LC remains controversial. This study evaluated operative outcomes and surgical difficulty of LC after ERCP in patients with gallstones and concomitant choledocholithiasis, with a particular focus on surgical timing.

We retrospectively reviewed patients who underwent LC after ERCP for choledocholithiasis. Difficult cholecystectomy was defined as the need for a bailout procedure, including conversion to open surgery or subtotal cholecystectomy, operative time > 180 min, or intraoperative blood loss ≥ 300 mL. Patients were classified according to the ERCP-LC interval as early (≤ 14 days), middle (15-60 days), or late (≥ 61 days). Operative outcomes were compared, and logistic regression analysis was performed to identify predictors of difficult cholecystectomy.

Among 1008 patients who underwent LC, 193 underwent preoperative ERCP. Forty-nine patients (25.4%) met the criteria for difficult cholecystectomy. The incidence was significantly higher in the middle group (33.0%) than in the early (7.7%, P = 0.036) and late groups (15.4%, P = 0.008). Postoperative complication rates did not differ among the groups; however, the late group had a higher incidence of recurrent biliary complications between ERCP and surgery. Multivariate analysis identified age ≥ 60 years, male sex, acute cholecystitis, and an ERCP-LC interval of 15-60 days as independent risk factors for surgical difficulty. Compared with the early and late groups, the 15-60-day interval was associated with increased odds of difficult cholecystectomy (OR 6.29 and 2.61, respectively).

An ERCP-LC interval of 15-60 days is associated with increased surgical difficulty. Surgeons should consider both surgical timing and interval biliary complications and be prepared to perform bailout procedures when necessary.