Resolution of Liver Function Tests After Laparoscopic Common Bile Duct Exploration Versus Endoscopic Retrograde Cholangiopancreatography

Abstract

Laparoscopic cholecystectomy (LC) with laparoscopic common bile duct exploration (LCBDE) is gaining traction for the management of choledocholithiasis. Liver function tests (LFTs) are often used to determine the success of ductal clearance, yet the impact of differing therapeutic interventions, endoscopic retrograde cholangiopancreatography (ERCP) or LCBDE, have on postprocedure LFT is insufficiently described. We hypothesize that these interventions have different postoperative LFT profiles. The preprocedural and postprocedural total bilirubin (Tbili), aspartate aminotransferase (AST), alanine aminotransferase (ALT), and alkaline phosphatase (ALP) were analyzed of 167 patients who had successful ERCPs (117) or LCBDEs (50). Endoscopic retrograde cholangiopancreatography patients demonstrated a significant decrease in all LFTs postprocedure (n = 117; P = <0.001 for all) with a continued downtrend when a second set of LFTs was obtained (n = 102; P = <0.001 for all). For successful LC+LCBDEs, there was no significant change between preoperative and 1st postoperative Tbili, AST, ALT, and ALP and the 2nd postoperative labs.

Spare the Needle, Discharge the Child: Trending Post-Op Labs After Laparoscopic Common Bile Duct Exploration in Pediatric Patients Is Not Helpful

“…This over reliance on post-procedural LFTs could lead to increased LOS, unnecessary additional interventions, and increased cost. 3 Additional lab draws required for postoperative LFTs also contribute to patient and caregiver distress, which is particularly relevant in treating pediatric patients. Only 2 studies have examined the effects of ductal manipulation occurring during LCBDE and how the procedure itself may negatively alter the postoperative LFT profile.…”

“…Only 2 studies have examined the effects of ductal manipulation occurring during LCBDE and how the procedure itself may negatively alter the postoperative LFT profile. 3,4 Both surmised that the force exerted on the biliary tree during LCBDE may lead to pressure differences within the intrahepatic ductal system, especially with an intact sphincter of Oddi. These forces and pressures could contribute to varying post-procedural LFT trends even with successful ductal clearance in the absence of sphincterotomy or biliary drain that is routinely employed during ERCP.…”

“…In contrast, LCBDE techniques rely on glucagon administration, power flushing with saline, and balloon dilation to facilitate stone migration into the duodenum. 3 The frequency of transcystic biliary stenting during LCBDE remains low, and thus, postoperative drainage of the biliary system is likely to be different between endoscopic and surgical approaches.…”

“…Two studies have indicated that LFT profiles in the postoperative setting are an unreliable marker of ductal clearance. 3,4 Wewelwala et al investigated potential LFT trends in the postoperative setting over a 3-year period. They concluded that postoperative LFTs are unreliable in predicting ductal clearance within the 48 hours after the operation due to the poor sensitivity and specificity of liver enzymes for obstructive biliary disease.…”

“…This finding is noteworthy as there are very few descriptions of this trend in children after interventions for benign biliary obstruction. 3,4 In the context of pediatric laparoscopic common bile duct exploration and postoperative liver function test (LFT) monitoring, it is crucial to recognize that if the LFTs following the intervention do not exhibit consistency, their utility diminishes. Obtaining these tests, in such cases, becomes counterproductive, leading to additional distress for the patient due to increased blood draws and prolonged hospital stays while awaiting a downtrend.…”