Selective use of ERCP in patients undergoing laparoscopic cholecystectomy

With the advent of laparoscopic cholecystectomy (LCH) various strategies have been proposed for the management of common bile duct (CBD) stones. In a consecutive series of 1140 patients subjected to LCH, preoperative endoscopic retrograde cholangiopancreatography (ERCP) was attempted in 128 patients (11.2%) and successfully accomplished in 121 (94.5%). Based on the prediction of CBD stones by laboratory tests, ultrasonography, and intravenous cholangiography, prelaparoscopic ERCP was performed in 106 patients (9.3%). CBD stones were identified in 56 patients and benign papillary stenosis in 5 patients (57.5%). Of these 61 patients, 58 (95%) were treated by endoscopic sphincterotomy (ES) and stone extraction followed by LCH after a mean interval of 1.6 days. Three patients with failure of endoscopic ductal stone extraction required open CBD exploration. In 39 of the 106 patients (36.8%) ERCP was negative for ductal stones but revealed unexpected ampullary and pancreatic cancer in two cases. Six patients (of the 106) with preoperative ERCP cannulation failure (5.7%) were managed either by LCH and intraoperative cholangiography or by open CBD exploration. In 22 of the 1140 total patients (1.9%) ERCP was performed at various intervals after LCH. Retained CBD stones were found in eight patients, and ES and ductal clearance was achieved in all eight. There was no mortality among the entire surgical group who underwent perioperative ERCP/ES. Including two cases of ES-related pancreatitis, the overall morbidity was 5.5% (7 of 128). Perioperative ERCP/ES in conjunction with LCH is an attractive approach for patients with cholecystocholedocholithiasis, at least until laparoscopic ductal clearance becomes a standard procedure.