SEQUENTIAL ENDOSCOPIC-LAPAROSCOPIC TREATMENT OF CHOLECYSTOCHOLEDOCHOLITHIASIS

Preoperative common bile duct (CBD) clearance with endoscopic retrogra de cholangiopancreatography (ERCP) and endoscopic sphincterotomy (ES) is routinely performed in many centers where laparoscopic cholecystect omy (LC) is the procedure of choice for the treatment of cholelithiasi s. The purpose of this study was to evaluate prospectively the results of the sequential endoscopic-laparoscopic management in patients with gallstones and suspected CBD stones. From November 1990 to May 1993, 700 consecutive patients were evaluated for LC, Preoperative workup in cluded clinical history and physical examination; serum levels of bili rubin, alkaline phosphatase, and amylase; and ultrasonography. Preoper ative ERCP was indicated in cases with previous or present jaundice or acute pancreatitis, altered liver or pancreatic blood tests, dilated CBD (>6 mm) and CBD stones at ultrasonography. If CDB pathology was co nfirmed, ES was performed and treatment attempted. All patients were a ssigned to undergo LC within 48 h. Morbidity, mortality, hospital stay , and disability were recorded. Of 700 patients, 49 (7%) underwent ERC P. In 26 patients (54.2%), CBD stones were identified; ES was performe d and stone extraction succeeded in 22 patients (84.6%). Two patients with intrahepatic stones were successfully treated with a percutaneous transhepatic approach and then underwent surgery. Two patients with c holecystocholedochal fistula underwent open surgery, In two cases ERCP showed a papillary stenosis, which was treated with ES. Of 44 patient s, 35 (79.5%) underwent LC within 48 h. The overall morbidity (ERCP/ES plus LC) was 10.4%. No mortality occurred. The mean hospital stay was 4.5 days. Return to normal activities occurred within 11 days after L C. This sequential approach resulted in a safe and effective treatment of cholecystocholedocholithiasis and a decrease in the overall costs.