intraoperative ERCP for management of cholecystocholedocholithiasis

Ahmed Elgeidie, Ehab Abdellattif, Gamal Elebidy, Yussef Elmahdy. gastroenterology surgical center

Background: Common bile duct stones (CBDS) are frequently diagnosed in patients with gallbladder stones (GBS). There is an agreement that these CBDS should be removed to prevent subsequent complications. The introduction of minimally invasive techniques in management of biliary problems added new procedures for treating such patients with cholecysto-choledocholithiasis (CCL). 

Aim of work: This study presents the results of intraoperative ERCP during laparoscopic cholecystectomy (LC) as a single-session minimally invasive procedure for management of patients who have GBS and concurrent preoperatively diagnosed CBDS.

Patients and methods: The data base of patients presented to our center by CCL who were treated by LC and intraoperative ERCP was collected and analyzed. CBDS were diagnosed using clinical data, laboratory tests and abdominal sonogram. Magnetic resonance cholangiography (MRC) was requested for doubtful cases. The study included patients who were operated between October 2007 and May 2015. In the first cases ERCP was done using Rendez-vous technique but in late cases we modified the technique to perform standard ERCP immediately after completion of LC under the same anesthesia. Preoperative, intraoperative and postoperative data were recorded, analyzed and reported. Data reported include success/failure rate, complications, conversion to open surgery, operative details and incidence of residual CBDS.

Results: The study was conducted on 346 patients who had CCL. The mean age was 24.7 years and 298 of them were females. The most common presentation was abdominal pain (91.6%) and jaundice (62%). The mean serum bilirubin level was 2.4 mg/dL. Fifteen patients were excluded and intraoperative ERCP was not done due to negative intraoperative cholangiogram results in 10 patients and conversion to open surgery in 5 patients due to acute cholecystitis (n=4) and intraoperative bleeding (n=1). Intraoperative ERCP was tried in the remaining 331 patients. Operative time ranged between 35 and 90 min with a mean of 47.4 min. the mean hospital stay was 1.4 (1-8) days. Failure of CBD clearance was reported in 12 patients (3.6%) with a success rate of 96.4%. There was no mortality. Complications were reported in 13 patients in the form of bleeding papillotomy (n=4), mild pancreatitis (n=3), transient hyperamylasemia (n=3), internal hemorrhage (n=1), incisional hernia (n=1), and cystic duct leakage (n=1). 30-day follow up was possible in 142 patients and there was no evidence of residual CBDS.

Conclusion: Intraoperative ERCP during LC is a safe and effective option for management of CCL.

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