“Ultra-rapid” sequential treatment in cholecystocholedocholithiasis: alternative same-day approach to laparoendoscopic rendezvous

Early Cholecystectomy after Endoscopic Retrograde Cholangiopancreatography Is Feasible and Safe

Laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP) is the preferred treatment for cholelithiasis with common bile duct stones. However, the optimal timing of LC after ERCP remains controversial. This study aimed to identify the ideal time interval between ERCP and LC. Data from patients who underwent LC after ERCP between November 2016 and August 2022 were retrieved from the electronic medical information system. The patients were categorized into early cholecystectomy (within 72 h of ERCP) and delayed cholecystectomy (after 72 h). The impact of the time interval between ERCP and LC on perioperative outcomes was analyzed. A total of 197 patients were included in the study, with 45 undergoing early cholecystectomy and 152 undergoing delayed cholecystectomy. No significant differences in the preoperative characteristics or operative morbidity were observed between the groups (p = 0.286). However, a significant correlation was found between the time interval from ERCP to LC and the total length of stay (r = -350, p < 0.001). The findings suggest that early cholecystectomy after ERCP is feasible and safe, and performing LC within the first 72 h does not adversely affect postoperative outcomes.

Comparison of different time intervals between laparoscopic cholecystectomy to endoscopic retrograde cholangiopancreatography for patients with cholecystolithiasis complicated by choledocholithiasis

Background

Endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC) is a common strategy for treatment of patients with gallstones with co-existing stones in the common bile duct (CBD). We conducted this study to compare the effect of different time intervals between ERCP and LC.

Methods

A total of 214 patients who underwent elective LC after ERCP for gallstones and CBD stones between January 2015 and May 2021 were retrospectively reviewed. We compared the hospital stay, operation time, perioperative morbidity, and conversion rate to open cholecystectomy, according to the interval between ERCP and ERCP and LC, namely, one day, 2–3 days, and 4 days or more. A generalized linear model was used to analyze the differences among the groups for outcomes.

Results

There were a total of 214 patients with 52, 80, and 82 patients in group 1, group 2, and group 3 respectively. These groups did not differ significantly in terms of major complications or conversion to open surgery (p = 0.503 and p = 0.358, respectively). The generalized linear model showed that operation times in group 1 and group 2 were similar (odds ratio (OR) 0.144, 95% confidence interval (CI) 12.597, 8.511, p = 0.704), while operation time was significantly longer in group 3 than in group 1 (OR 4.005, 95% CI, 0.217, 20.837, p = 0.045). Post-cholecystectomy hospital stay was similar among the three groups, while post-ERCP hospital stay was significantly longer in group 3 compared with group 1.

Conclusion

We recommend that LC be performed within three days after ERCP to reduce operating time and hospital stay.

A retrospective cohort study on the optimal interval between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy

Endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) are the most important procedures for patients with choledocholithiasis and gallstones. Many studies recommend early LC after ERCP; however, there is still no consensus on the optimal interval between the two. The purpose of this study was to investigate the appropriate timing of LC after ERCP in patients with choledocholithiasis and cholecystolithiasis. We retrospectively reviewed all ERCPs in our institution from November 2014 to August 2021. All eligible 261 patients were divided into ERCP-LC1 (≤3 days), ERCP-LC2 (3-7 days), and ERCP-LC3 (>7 days). We also reviewed 90 patients with elective LC as the LC group. Procedures, treatment outcomes, and postoperative adverse events were evaluated. In a total of 1642 ERCPs, 261 eligible patients were divided into ERCP-LC1 (n = 102), ERCP-LC2 (n = 113), and ERCP-LC3 (n = 46). The ERCP-LC groups had no difference in operation time, postoperative adverse events, and open conversion rate with the LC group, but the total hospital stay and hospital stay after LC were longer than the LC group. There were no differences between the ERCP-LC groups in operation time, hospital stay after LC, open conversion rate, postoperative adverse events, and efficacy. However, LC within 7 days and even 3 days after ERCP had significant advantages in improvement in total length of stay and medical expenses. Furthermore, we also found an increased risk of gallbladder gangrene and perforation in LC >7 days after ERCP. LC within 7 days and even 3 days after ERCP is a safe, effective, and economical method for patients with choledocholithiasis and gallstones.

Destiny for Rendezvous: Is Cholecysto/Choledocholithiasis Better Treated with Dual- or Single-Step Procedures?

Biliary lithiasis is common worldwide, affecting almost 20% of the general population, though few experience symptoms. The frequency of choledocholithiasis in patients with symptomatic cholelithiasis is estimated to be 10-33%, depending on patients' age. Unlike gallbladder lithiasis, the medical and surgical treatment of common bile duct stones is uncertain, having changed over the last few years. The prior gold standard treatment for cholelithiasis and choledocholithiasis was open cholecystectomy with bile duct clearance, choledochotomy, and/or surgical sphincterotomy. In the last 10-15 years, new treatment approaches to the complex pathology of choledocholithiasis have emerged with the advent of endoscopic retrograde cholangiopancreatography (ERCP), laparoscopic surgery, and advanced diagnostic procedures. Although ERCP followed by laparoscopic cholecystectomy is the preferred mode of management, a single-step strategy (laparo-endoscopic rendezvous) has gained acceptance due to lesser morbidity and a lower risk of iatrogenic damage. Given the above, a tailored approach relying on careful evaluation of the disease is necessary in order to minimize complication risks and overall costs. Yet, the debate remains open, with no consensus on the superiority of laparo-endoscopic rendezvous to more conventional approaches.

Optimal timing of laparoscopic cholecystectomy post-endoscopic retrograde cholangiography and common bile duct clearance: A prospective observational study

Background:

The treatment of patients with cholelithiasis with common bile duct (CBD) stones is CBD clearance with cholecystectomy. While traditional teachings advocate waiting for 4–6-week post-endoscopic retrograde cholangiography (ERCP) with CBD clearance, recent studies favour an early laparoscopic cholecystectomy (LC). Hence, this study was conducted to evaluate the optimal timing of LC post-ERCP.

Methods:

We conducted a prospective observational study between March 2017 and October 2018. Patients diagnosed with cholelithiasis and CBS stones on ultrasonography or computed tomography were included. They were assigned to one of two groups (<2 weeks and >2 weeks) based on the time interval between ERCP and subsequent LC. Chi-square test was used to analyse the intraoperative and post-operative outcomes between the two study groups,

Results:

One hundred and forty patients were included in the study of which 69 underwent an early LC (<2 weeks). There was a significant decrease in the blood loss and incidence of bowel injury in the early group. Calots triangle was better defined and critical view of safety was achieved more in the patients who underwent an early LC. This resulted in a significantly lower incidence of drain placement and length of hospital stay in those patients who underwent an early LC.

Conclusion:

A delay of 2 weeks after ERCP makes the LC more difficult and is associated with a longer hospital stay. We advocate LC within 2 weeks of ERCP whenever feasible.

Clinical Impact of Preoperative Relief of Jaundice Following Endoscopic Retrograde Cholangiopancreatography on Determining Optimal Timing of Laparoscopic Cholecystectomy in Patients with Cholangitis

Background: About 10% of patients with gallbladder (GB) stones also have concurrent common bile duct (CBD) stones. Laparoscopic cholecystectomy (LC) after removal of CBD stones using endoscopic retrograde cholangiopancreatography (ERCP) is the most widely used method for treating coexisting gallbladder and common bile duct stones. We evaluated the optimal timing of LC after ERCP according to clinical factors, focusing on preoperative relief of jaundice. Methods: A total of 281 patients who underwent elective LC after ERCP because of choledocholithiasis and cholecystolithiasis from January 2010 to April 2018 were retrospectively reviewed. We compared the hospital stay, perioperative morbidity, and rate of surgical conversion to open cholecystectomy according to the relief of jaundice before surgery. These enrolled patients were divided into two groups: relief of jaundice before surgery (group 1, n = 125) or not (group 2, n = 156). Results: The initial total bilirubin level was higher in group 1; however, there were no significant differences in the other baseline characteristics including age, sex, American Society of Anesthesiologists score, previous surgical history, white blood cell count, C-reactive protein, and operative time between the two groups. There was also no significant difference in postoperative hospital stay between the two groups (4.5 ± 3.3 vs. 5.5 ± 5.6 days, p = 0.087). However, after ERCP, the waiting time until LC was significantly longer in group 1 (5.0 ± 4.9 vs. 3.5 ± 2.4 days, p < 0.001). There were no statistical differences in the conversion rate (3.2% vs. 3.8%, p = 0.518) or perioperative morbidity (4.0% vs. 5.8%, p = 0.348), either. Conclusions: LC would not be delayed until the relief of jaundice after ERCP since there were no significant differences in perioperative morbidity or surgical conversion rate to open cholecystectomy. Early LC after ERCP may be feasible and safe in patients with cholangitis and cholecystolithiasis.

Bile duct clearance and cholecystectomy for choledocholithiasis: Definitive single-stage laparoscopic cholecystectomy with intraoperative endoscopic retrograde cholangiopancreatography versus staged procedures

BACKGROUND

Clinical equipoise exists regarding optimal sequencing in the definitive management of choledocholithiasis. Our current study compares sequential biliary ductal clearance and cholecystectomy at an interval to simultaneous laparoendoscopic management on index admission in a pragmatic retrospective manner.

METHODS

Records were reviewed for all patients admitted between January 2015 and December 2018 to a Swedish and an Irish university hospital. Both hospitals differ in their practice patterns for definitive management of choledocholithiasis. At the Swedish hospital, patients with choledocholithiasis underwent laparoscopic cholecystectomy with intraoperative rendezvous endoscopic retrograde cholangiopancreatography (ERCP) at index admission (one stage). In contrast, interval day-case laparoscopic cholecystectomy followed index admission ERCP (two stages) at the Irish hospital. Clinical characteristics, postprocedural complications, and inpatient duration were compared between cohorts.

RESULTS

Three hundred fifty-seven patients underwent treatment for choledocholithiasis during the study period, of whom 222 (62.2%) underwent a one-stage procedure in Sweden, while 135 (37.8%) underwent treatment in two stages in Ireland. Patients in both cohorts were closely matched in terms of age, sex, and preoperative serum total bilirubin. Patients in the one-stage group exhibited a greater inflammatory reaction on index admission (peak C-reactive protein, 136 ± 137 vs. 95 ± 102 mg/L; p = 0.024), had higher incidence of comorbidities (age-adjusted Charlson Comorbidity Index, ≥3; 37.8% vs. 20.0%; p = 0.003), and overall were less fit for surgery (American Society of Anesthesiologists, ≥3; 11.7% vs. 3.7%; p < 0.001). Despite this, a significantly shorter mean time to definitive treatment, that is, cholecystectomy (3.1 ± 2.5 vs. 40.3 ± 127 days, p = 0.017), without excess morbidity, was seen in the one-stage compared with the two-stage cohort. Patients in the one-stage cohort experienced shorter mean postprocedure length of stay (3.0 ± 4.7 vs. 5.0 ± 4.6 days, p < 0.001) and total length of hospital stay (6.5 ± 4.6 vs. 9.0 ± 7.3 days, p = 0.002). The only significant difference in postoperative complications between the cohorts was urinary retention, with a higher incidence in the one-stage cohort (19% vs. 1%, p = 0.004).

CONCLUSION

Where appropriate expertise and logistics exist within developing models of acute care surgery worldwide, consideration should be given to index-admission laparoscopic cholecystectomy with intraoperative ERCP for the treatment of choledocholithiasis. Our data suggest that this strategy significantly shortens the time to definitive treatment and decreases total hospital stay without any excess in adverse outcomes.

LEVEL OF EVIDENCE

Therapeutic/Care Management Level IV.

Same-day endoscopic ultrasound, retrograde cholangiopancreatography and stone extraction, followed by cholecystectomy: A case report and literature review

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The risk of recurrence or complications is high after a common bile duct stone related event.

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Cholecystectomy should be carried out soon after extraction of a common bile duct stone.

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Same-day investigation, endoscopic stone extraction and cholecystectomy is feasible and safe.

Introduction

Common bile duct stone-related events and their recurrence are frequent even after endoscopic retrograde cholangiopancreatography and stone extraction. Cholecystectomy should be carried out as soon as possible after the initial episode to prevent complications.

Case presentation

We present a case of a patient who underwent endoscopic ultrasound, cholangiopancreatography with stone extraction and cholecystectomy on the same day.

Discussion

After a common bile duct stone-related event, investigation, and stone extraction, cholecystectomy should be carried out as soon as possible to avoid high rates of recurrence and complications. Rise in health care costs nowadays mandate such an approach as a pre-emptive measure to prevent health complications while lowering health costs.

Conclusion

Diagnosis of common bile duct stone followed by extraction with endoscopic cholangiopancreatography and cholecystectomy on the same day is feasible, safe, and has many potential advantages.

Same-Day versus Conventional Different-Day Endoscopic Retrograde Cholangiopancreatography and Laparoscopic Cholecystectomy: A Multi-Center Retrospective Study

Same-day endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy (LC) could potentially reduce hospital length of stay (HLOS). Patients undergoing same-day procedures (N = 164) between 2012 and 2014 were compared with different-day procedures performed in the second half of 2014 (N = 276), in the Kaiser Permanente Southern California database. Both groups had comparable baseline characteristics. ERCP success rate (97.5% vs 93.5%), overall postoperative morbidity (3.66% vs 3.99%), and retained stones (2.5% vs 5.8%) were not different between groups ( P > 0.05); however, HLOS was shorter in the same-day group (2.99 ± 2.34 vs 3.84 ± 2.52 days, P < 0.001). Morbidity, procedure success, and HLOS were not different in the same-day group, whether ERCP was performed before or after LC ( P > 0.05). In the same-day group, those undergoing single anesthesia had higher BMI (40.1 ± 10.8 vs 30.3 ± 6.6) and were more likely to have gastric bypass (30% vs 0%) than those undergoing separate anesthesia sessions ( P < 0.01). Longer HLOS (4.8 ± 3.5 vs 2.9 ± 2.2 days) and higher estimated blood loss (65 ± 90 mL vs 20 ± 29 mL) were also associated with the single-anesthetic session ( P < 0.01). ERCP performed on the same day of LC reduces HLOS without increasing morbidity. This approach does not affect postoperative morbidity and ERCP success rate, whether ERCP was performed before or after LC.

Optimal Timing for Laparoscopic Cholecystectomy After Endoscopic Retrograde Cholangiopancreatography: A Systematic Review

Background and Aims:

Endoscopic retrograde cholangiopancreatography followed by laparoscopic cholecystectomy is often used as definitive treatment for common bile duct stones. The aim of this study was to investigate the optimal time interval between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Materials and Methods:

PubMed and Embase were searched for studies comparing different time delays between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy. Observational studies and randomized controlled trials were included. Primary outcome was conversion rate from laparoscopic to open cholecystectomy and secondary outcomes were complications, mortality, operating time, and length of stay.

Results:

A total of 14 studies with a total of 1930 patients were included. The pooled estimate revealed an increase from a 4.2% conversion rate when laparoscopic cholecystectomy was performed within 24 h of endoscopic retrograde cholangiopancreatography to 7.6% for 24–72 h delay to 12.3% when performed within 2 weeks, to 12.3% for 2–6 weeks, and to a 14% conversion rate when operation was delayed more than 6 weeks.

Conclusion:

According to this systematic review, it is preferable to perform cholecystectomy within 24 h of endoscopic retrograde cholangiopancreatography to reduce conversion rate. Early laparoscopic cholecystectomy does not increase mortality, perioperative complications, or length of stay and on the contrary it reduces the risk of reoccurrence and progression of disease in the delay between endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Single-session laparoscopic cholecystectomy and ERCP: a valid option for the management of choledocholithiasis

BACKGROUND AND AIMS

The option for performing ERCP and laparoscopic cholecystectomy (LC) for the management of choledocholithiasis in the same operative session is often overlooked. We compared the success, safety, and cost of ERCP and LC when performed in either a single session or in separate sessions.

METHODS

We conducted a retrospective cohort study at a U.S. tertiary care hospital. We identified patients undergoing ERCP and LC between April 2011 and August 2014 in either a single operative session (n = 33) or in 2 separate sessions within a 30-day period (n = 80). Technical success, total anesthesia duration, operative time, length of hospitalization, cost of care, and morbidity and mortality were evaluated.

RESULTS

Bile duct clearance was achieved in all patients at ERCP in the same-session cohort. The separate versus single-session groups, respectively, did not differ in terms of total procedure times (mean ± SD = 142 ± 64 vs 142 ± 58 min; t test, P =.98), anesthesia duration (251 ± 64 vs 225 ± 69 min; P =.06), or overall cost (49.3 ± 24.5 vs 42.3 ± 23.2 ×1000 USD; P =.167), but hospitalization was longer in the separate-sessions group (6.2 ± 3.3 vs 4.8 ± 2.6 days; P =.03). The rates of adverse events were similarly low (7% vs 2%, P =.70).

CONCLUSIONS

Performing single-session ERCP and LC is safe, effective, economically viable, and reduces hospital stay compared with performing ERCP and LC during separate sessions.