The role of ERCP in patients after laparoscopic cholecystectomy

The goal of this study was to evaluate the feasibility of endoscopic management of complications encountered in patients undergoing laparoscopic cholecystectomy. Special attention was given to establishing the optimal timing, success rate, and complications of diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) after laparoscopic cholecystectomy.

Fifty-six consecutive patients referred from two major medical centers were evaluated with ERCP after laparoscopic cholecystectomy. The patient population included 22 men and 34 women 16-87 yr of age. Indications included common bile duct stones seen on operative cholangiography or ultrasound, persistently elevated liver enzymes and abdominal pain, evidence of biliary injury, and other, All endoscopic procedures were carried out by experienced endoscopists using standard ERCP techniques and equipment. Endoscopic papillotomy was performed with 2- to 2.5-cm cutting wire papillotomes and all biliary stones were removed with 8.5- to 14-mm balloons. Small biliary leaks were first treated with 3-7 days of nasobiliary drainage, and if persistent with 10-Fr internal stents for 1 month. One patient with a biliary stricture was dilated with placement of progressively larger biliary stents over 9-month period.

ERCP was performed within 6 h to 2 yr after laparoscopic cholecystectomy (LC). In 12 patients, it was performed within the first 24 h after LC. A cholangiogram was obtained in all patients. No complications were encountered. Thirty patients underwent therapeutic endoscopy. Common bile duct stones were found and were successfully removed from 23 patients. One patient required an emergent ERCP and sphincterotomy for gallstone pancreatitis 3 days after LC. Fourteen patients had common bile duct injuries, cystic duct stump leaks, or leakage from ducts of Luschka (one patient). All leaks were successfully treated with temporary stenting. Six patients with bile duct transection or complete obstruction by clips required surgical therapy. One patient with a common bile duct stricture was managed with endoscopic stents alone. Two patients had unsuspected malignancies, one each with ampullary and pancreatic carcinoma. Fourteen patients had a normal ERCP.

Diagnostic and therapeutic ERCP can be done within 24 h of LC with safety and a high degree of success. Delay in removal of CBD stones may lead to complications. Cystic duct stump leaks are easily corrected with nasobiliary drainage, and some post-LC strictures may be amenable to therapy with biliary stents. Finally, malignancy must be excluded in patients with unexplained recurrent symptoms.