ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY AND LAPAROSCOPIC CHOLECYSTECTOMY

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful adju nct to laparoscopic cholecystectomy. Preoperative ERCP is indicated if there is a high degree of suspicion for common duct stones, when seve re gallstone-induced pancreatitis is present, or when there is uncerta inty regarding the diagnosis. The best indicators of common duct stone s preoperatively are an elevated bilirubin, a dilated common bile duct (CBD) on sonography, or stones visualized in the CBD on sonography. M ild gallstone pancreatitis and transient mild elevations in liver enzy mes are not predictive of CBD stones and are not indications for ERCP. Postoperative ERCP is highly effective in clearing CBD stones. It has the advantage of being more readily available as compared to laparosc opic CBD exploration, and preserves all the advantages of the laparosc opic approach. Postoperative ERCP is indicated for retained CBD stones , evaluation and therapy of biliary injuries, and persistent biliary s ymptoms or abnormal liver enzymes and bilirubin. ERCP is the procedure of choice for the evaluation of laparoscopic biliary injuries. Major biliary injuries will generally require surgical therapy. Bile duct st rictures are sometimes amenable to endoscopic therapy with dilation an d stents. Biliary leaks are readily treatable with endoscopic therapy. Small cystic duct stump leaks and leaks from a duct of Lushka close w ithin a few days with nasobiliary drainage. Larger leaks may require m ore prolonged drainage with stents and early supplemental percutaneous drainage of an accompanying biloma. Bilious ascites should be treated with nasobiliary drainage using low suction to be prevent contaminati on of the peritoneal cavity with intestinal flora, and simultaneous pe rcutaneous ascites drainage. Biliary leaks, unless associated with maj or bile duct injuries, rarely require surgical therapy.