MANAGEMENT AND LONG-TERM FOLLOW-UP OF PATIENTS WITH POSITIVE CHOLANGIOGRAMS DURING LAPAROSCOPIC CHOLECYSTECTOMY

BACKGROUND: With a goal of minimal invasion during laparoscopic cholec ystectomy, the surgeon confronts a judgement decision if the intraoper ative cholangiography (IOC) is positive for common bile duct (CBD) sto nes. The options are postoperative endoscopic retrograde cholangiopanc reatography (ERCP) with endoscopic papillotomy (EP), transcystic lapar oscopic techniques (LAP), open CBD exploration, or clinical observatio n. PATIENTS AND METHODS: To gather this information, we reviewed the c linical course and IOC of 55 patients with positive IOC during laparos copic cholecystectomy. Long-term follow-up (1.8 years) was obtained in 50 patients. RESULTS: After review, 48 patients were felt to have CBD stones, and a LAP without choledochoscopy was the initial management in 32 (67%) patients. The remaining patients underwent EP (n = 10), CB D exploration (n = 1), or observation (n = 5). By discharge, 19 (59%) of the 32 LAP patients were successful and had avoided EP while the su ccess rate at follow-up was 48% (14/29). There were no complications a fter LAP, but we observed a 9.5% (2/21) post-EP pancreatitis rate that required readmission. The success rate for CBD stone clearance with L AP was associated with single stones (87%) and surgeon experience (100 % in the last year). The average hospital stay was 1.7 days for LAP an d 3.3 days for EP. CONCLUSIONS: LAP is safe and eliminates the need fo r EP in the majority of cases. Although EP is more often successful, i t results in a longer hospital stay with an increased risk of complica tion. We recommend LAP as the initial procedure of choice for a positi ve IOC.