Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy

Few laparoscopic surgeons currently explore the bile duct at cholecystectomy, which has focused attention on the role of preoperative endoscopic retrograde cholangiopancreatography (ERCP) in the diagnosis and treatment of duct stones. Indications for ERCP depend on the likelihood of duct pathology; clinical, biochemical, and radiologic predictive factors are well established. Expert endoscopists use ERCP sparingly, only in patients known or very likely to have duct stones, believing that the duct can be cleared after laparoscopic cholecystectomy (LC) when necessary in almost every case. Paradoxically, when the level of local ERCP expertise is modest, ERCP may be attempted before LC more often, thus leaving the option of open exploration if ERCP fails. ERCP is highly efficient in the management of patients with symptoms after LC in order to exclude, diagnose, and treat complications such as retained stones, cystic duct leaks, and strictures. Concern about performing sphincterotomy in young patients (especially those with normal-sized ducts) because of unknown long-term effects is leading some endoscopists to remove small stones through the intact papilla. Selected patients with gallbladder and duct stones may be best treated by endoscopic duct clearance alone, without cholecystectomy (unless or until symptoms develop). Overall, ERCP techniques are currently used in about 10% of patients before or after LC. Each surgical/endoscopic team should develop an algorithm to maximize the effectiveness of the combined approach and to minimize problems.