Preoperative ERCP Approach to Common Bile Duct Stones:Results of a Selective Policy

Abstract

Background: In a previous study, we made a plea for more selective indications for preoperative ERCP in patients with gallstones based on the results obtained from a liberal policy. Following 3.5 years of implementing this selective policy, a report on the results are presented here. This study was performed in a referral academic hospital. Methods: Between June 1994 and December 1997, 328 patients underwent cholecystectomy because of symptomatic cholelithiasis. Absolute indications for preoperative ERCP were: acute cholangitis (4 patients); obstructive jaundice (22 patients); gallstone pancreatitis (within the first 24 h in 14 patients), and wide common bile duct (CBD, >8 mm) with suspicion of stones in the biliary tree (2 patients). Results: In 42 patients (12.8%) a preoperative ERCP was performed for these indications. Stones were found in the CBD in 30 patients and edema in the papilla in 2 patients (total 76.2%). The stones could be extracted by endoscopic sphincterotomy in 24 of the 30 patients (80%). Complications were seen in 7 patients (16.7%). All these complications (bleeding of the papilla in 4 and mild pancreatitis in 3 patients) could be treated conservatively. During a mean follow-up of 2.5 years, CBD stones could be demonstrated postoperatively in 3 patients (0.3%). No mortality was observed in this series. Conclusions: The results of this selective policy included the expected outcome of a significant reduction in the number of ERCPs performed from 29 to 12.8% (p < 0.001, χ² test) and a better yield of stones, from 29 to 76.2% of the patients. The mortality of the procedure decreased from 2 to 0% whereas morbidity remained the same. This selective policy seems adequate for the preoperative assessment of CBD stones.

For patients with predicted low risk for choledocholithiasis undergoing laparoscopic cholecystectomy, selective intraoperative cholangiography and postoperative endoscopic retrograde cholangiopancreatography is an effective strategy to limit unnecessary procedures

“…Although preoperative studies, such as LFTs and ultrasound findings, and clinical data, such as recent pancreatitis, cholangitis, or obstructive jaundice, are not particularly reliable, several studies have supported the practice of selective preoperative ERCP based on the above factors followed by laparoscopic cholecystectomy [8][9][10][11][12][13]33]. It has been suggested by some, in an attempt to limit the number of negative ERCPs before laparoscopy, that preoperative ERCP should be reserved for patients who have documented choledocholithiasis, acute cholangitis, or severe biliary pancreatitis [3,14,18,33]. When IOC demonstrates choledocholithiasis, the choices include: (1) proceed to postoperative ERCP, (2) single-stage laparoscopic procedure with cholecystectomy and laparoscopic bile duct exploration [15,16], or, occasionally, (3) open bile duct exploration.…”

Magnetic Resonance Cholangiopancreaticography as a Diagnostic Tool for Common Bile Duct Stones

“…Using ERCP as a diagnostic procedure to exclude CBD stones in patients undergoing laparoscopic cholecystectomy can lead to performing an ERCP in up to 30% of the patients with sometimes over 50% negative findings, but with associated morbidity. A selective policy can lead to a significant reduction in the number of ERCPs performed and a better yield of stones [19, 20]. …”

Effect of Medical or Surgical Admission on Outcome of Patients with Gallstone Pancreatitis and Common Bile Duct Stones

“…A number of algorithms using combinations of one-and two-stage surgical and endoscopic approaches that likely morbidity and mortality. [1][2][3][4][5][6][7][8][9][10][11] Others advocate endoscopicbased therapy as a means of decreasing immediate morbidity and mortality particularly in patients who are high-risk surgical candidates, who are in a center with skilled endoscopists, and in whom there is a high suspicion of CBDS. [12][13][14] Recently, a meta-analysis of 12 studies revealed that outcome-defined as successful duct clearance, mortality, overall morbidity, and need for additional procedures-was not significantly different between surgery-only and endoscopy-plus-surgery-treated groups.…”