COMPARISON OF ROUTINE AND SELECTIVE ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY BEFORE LAPAROSCOPIC CHOLECYSTECTOMY

To evaluate the role of endoscopic retrograde cholangiography (ERC) be fore laparoscopic cholecystectomy, we compared the frequency of concom itant common bile duct stones, their clinical outcome, and the frequen cy of bile duct injury between a group of 128 patients with routine pr eoperative ERC (group A) and 1010 patients with selective ERC (group B ). Overall, 48 patients (4.2%) had duct stones, but the predictive sig ns were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 3 7 patients in group B, 22 were diagnosed by selective ERC and underwen t endoscopic removal. Of four patients whose stones were found by oper ative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphin cterotomy, which failed in one. The stones were not recognized until p ain recurred in the remaining 11 patients. Sphincterotomy was successf ul in nine patients but failed in the other two. Thus postoperative sp hincterotomy failed in 3 of 13 patients (23%), necessitating open surg ery. Forty-two patients overall (3.7%) had aberrant biliary tract anat omy, which did not lead to bile duct injury in any of the patients. Mo rbidity of routine ERC (3.1%) was lower than that of selective ERC (7. 4%) (p < 0.05). It should be noted that a certain proportion of duct s tones may be missed by selective ERC, necessitating laparotomy when sp hincterotomy fails. The routine use of preoperative ERC may be justifi ed at institutions where the expertise is available, at least until la paroscopic lithotomy becomes easy.