Simultaneous cholecystectomy and ERCP: an option omitted in the current choledocolithiasis management guidelines

J V Harmon, MD, PhD1, R Mallick, MD1, K Rank, MD2, C Ronstrom, BS3, M Arain, MD4, M L Freeman, MD4. 1University of Minnesota Department of Surgery, 2University of Minnesota Department of Medicine, 3University of Minnesota Medical School, 4University of Minnesota Department of Medicine, Division of Gastroenterology

INTRODUCTION – We report the feasibility and safety of performing laparoscopic cholecystectomy and ERCP as a single-stage procedure in comparison to performing these procedures sequentially as two separate procedures for the management of choledocholithiasis. The option for performing these procedures under the same anesthetic is often overlooked. Guidelines for management of choledocolithiasis that omit the option for simultaneous laparoscopic cholecystectomy and ERCP include those endorsed by: SAGES, British Society of Gastroenterology, Association of Upper Gastrointestinal Surgeons of Great Britain and Ireland, and Association of Laparoscopic Surgeons. In our academic hospital setting, performing single-stage laparoscopic cholecystectomy and ERCP procedures is an option given our active ERCP group.

METHODS AND PROCEDURES – Using the electronic medical record system, we retrospectively reviewed outcomes for patients undergoing both ERCP and laparoscopic cholecystectomy for choledocholithiasis from April 2011 until September 2013. We identified 18 patients who underwent these procedures simultaneously under a single anesthetic and compared the patient outcomes to those in a cohort of 30 consecutive control patients from the same time period who underwent these procedures sequentially under two separate anesthetics. The data was analyzed using Fisher’s exact test; all tests were two-tailed.

RESULTS – Patient demographic characteristics including age, gender, and ASA scores were similar between the two groups. The average combined operative time for simultaneous procedures was 142 &plusnm; 66 minutes, while the average combined operative time for the sequential procedures was 129 &plusnm; 39 minutes; the difference in average total operative times was not statistically significant. The average total anesthesia times were not significantly different between the two cohorts: the average total anesthesia time was 227 &plusnm; 67 minutes for those done simultaneously, and 238 &plusnm; 51 minutes when these procedures were performed separately. Median hospital length of stay was 5 days for both groups; there was no statistically significant difference between the average lengths of stay for the two groups. There was no difference in the rates of major complications betwen the two groups. Conversion to open surgery did not occur in either group. There were no bile duct injuries, and 30 day mortality was zero in both groups.

CONCLUSIONS- Performing cholecystectomy and ERCP during a single anesthetic is feasible given the active ERCP service at our academic hospital. During simultaneous procedures, we found it advantageous to perform the laparoscopic cholecystectomy first to avoid limiting exposure and visibility during laparoscopic surgery due to intraluminal endoscopic CO2 insufflation associated with ERCP procedures. Recent guidelines for the care of patients with choledocolithiasis should include the option to perform laparoscopic cholecystectomy and ERCP during the same anesthetic.

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