Endoscopic management of bile duct stones

Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy

BACKGROUND

We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using "stricter criteria" to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs).

METHODS

A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using "stricter criteria" (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively.

RESULTS

Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying "stricter criteria" to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs.

CONCLUSIONS

Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using "stricter criteria" to select patients for preoperative ERCP can avoid unnecessary ERCPs.

The role of endoscopic retrograde cholangiopancreatography in patients with laparoscopic cholecystectomies

BACKGROUND & AIMS

The best clinical strategy for using endoscopic retrograde cholangiopancreatography (ERCP) with laparoscopic cholecystectomy is unknown. The aim of this study is to use decision analysis to assess four different approaches to using ERCP in patients undergoing laparoscopic cholecystectomy.

METHODS

Decision trees were designed for four clinical strategies: (1) preoperative ERCP, with sphincterotomy for choledocholithiasis; (2) selective preoperative ERCP for patients at high risk for choledocholithiasis, choledocholithiasis found at surgery treated by postoperative ERCP; (3) no preoperative ERCP, choledocholithiasis detected intraoperatively treated by postoperative ERCP; and (4) no preoperative ERCP, choledocholithiasis detected intraoperatively treated with open common bile duct exploration. Using decision analysis with literature-derived data, the impact on outcome parameters was calculated.

RESULTS

Postoperative ERCP resulted in the lowest cost, procedure numbers, and hospital and back-to-work days. With high preoperative likelihood of choledocholithiasis, selective preoperative ERCP was probably a clinically equivalent strategy. Sensitivity analysis supported these conclusions when the probabilities and utilities were varied over a wide range. The open operative approach to choledocholithiasis was only favored if ERCP had < 75% diagnostic and < 50% therapeutic success rates or lengthened hospitalization by > 7 days.

CONCLUSIONS

This study suggests that performing ERCP after laparoscopic cholecystectomy minimizes costs and morbidity; however, when choledocholithiasis is likely, selective preoperative ERCP may be a clinically equivalent strategy.