ERCP IN ASSOCIATION WITH LAPAROSCOPIC CHOLECYSTECTOMY - A STRATEGY TOMINIMIZE THE NUMBER OF UNNECESSARY ERCPS

Background: With the evolution of laparoscopic cholecystectomy (LC) as the standard operation for benign gallbladder disease, the role of en doscopic retrograde cholangiopancreatography (ERCP) in the management of common bile duct (CBD) stones has to be defined. Methods: From Nove mber 1990 to April 1994 we attempted LC in 1,788 patients. Eighty-nine patients underwent ERCP preoperatively under the following indication s: jaundice or a history of jaundice, cholangitis, gallstone pancreati tis, abnormal liver function tests, and a sonogram showing either CBD stones or a dilated CBD. With intent to minimize the number of unneces sary ERCPs only patients with jaundice, cholangitis, and high abnormal ities on the liver function tests (LFTs) were directly referred for ER CP. All other patients with suspected choledocholithiasis were initial ly investigated with intravenous cholangiography (IVC) and tomography; only patients with positive findings on IVC subsequently underwent ER CP. Eighteen patients underwent ERCP postoperatively and the indicatio ns included jaundice, bile leak, and abnormal intraoperative cholangio gram. Results: Of the 89 patients having ERCP preoperatively 54 patien ts (60.7%) were found to have CBD stones which were removed endoscopic ally in all cases except in one patient where a large CBD stone was re moved during laparoscopic exploration of the CBD. Eight patients of th e 18 patients having ERCP postoperatively were found to have CBD stone s and all of them had their CBD cleared endoscopically. There were no mortalities, while four patients developed a mild pancreatitis. Conclu sions: Although there is an increasing tendency to clear the bile duct with a laparoscopic approach, ERCP and sphincterotomy has a certain r ole in conjunction with LC in the management of patients with a high s uspicion of CBD stones, particularly in institutions where there is ea sy access to expert interventional endoscopic techniques.