Victor Vakayil, MD, MS1, Samuel T Klinker, BS1, Megan L Sulciner, BS1, Reema Mallick, MD2, Stuart Amateau, MD, PhD1, Guru Trikudanathan, MD1, Martin Freeman, MD1, James Harmon, MD, PhD1. 1University of Minnesota, 2University of Pittsburgh,
BACKGROUND: Up to 18% of patients undergoing laparoscopic cholecystectomies (LC) for cholelithiasis have concurrent choledocholithiasis. While the majority of common bile duct stones pass spontaneously, larger stones require definitive removal to prevent significant morbidity. LC is recognized as the criterion standard for treating patients with symptomatic gallstones disease, however, the optimal choice for the extraction of biliary duct calculi remains unaddressed. Current favor lies with endoscopic retrograde cholangiopancreatography (ERCP), with the timing of the procedure being an active area of research. As the technical skill set for laparoscopy increases, laparoscopic common bile duct exploration (LCBDE) remains an alternative to ERCP.
METHODS: We utilized the American College of Surgeons, National Surgical Quality Improvement Project (NSQIP) database to retrospectively analyze postoperative outcomes for all patients undergoing LC for cholelithiasis with presumed choledocholithiasis from 2012 to 2016. Using ICD-9/10 and CPT codes we stratified patients into two cohorts; those being managed with intraoperative ERCP (i-ERCP) or LCBDE. Outcomes were measured using the Clavien-Dindo grading of postoperative complications within 30 days of LC. All patients undergoing additional procedures, other than ERCP or LCBDE, in conjunction with LC were excluded.
RESULTS: A total of 1,331 patients undergoing LC, with either LCBDE (n=837, 63%) or i-ERCP (n=494, 37%) were identified. The majority of patients included were Caucasian and female, with no significant difference in demographics, preoperative comorbidities, preoperative labs, preoperative sepsis or ASA scores (with exception of preoperative diabetes, i-ERCP; 11.1%, N = 55, vs LCBE; 15.7%, N = 131; P = 0.022 – Table 1). Clavien-Dindo graded outcomes (Table 2) showed no significant differences for Grades I, II, III, IV or V showing the efficacy of both treatment modalities. Mortality rates (Grade V) were low for both i-ERCP (0.6%, N = 3) and LCBDE (1.1%, N=9). Reoperation rates were comparable between both groups ( i-ERCP: 1.9 %, N= 16 vs. LCBDE: 1.6%, N = 8, P = 0.699).
CONCLUSION: Intraoperative ERCP and LCBDE result in comparably low postoperative morbidity and mortality. Institutions with skilled and readily available endoscopic facilities may favor i-ERCP due to ease of access and reduced operative time; however, LCBDE remains an appropriate surgical technique for the treatment of concurrent choledocholithiasis, especially when immediate endoscopic intervention remains unavailable.
Presented at the SAGES 2017 Annual Meeting in Houston, TX.
Abstract ID: 95621
Program Number: S005
Presentation Session: Biliary
Presentation Type: Podium