THE ROLE OF ERCP IN PATIENTS AFTER LAPAROSCOPIC CHOLECYSTECTOMY

Objectives: The goal of this study was to evaluate the feasibility of endoscopic management of complications encountered in patients undergo ing laparoscopic cholecystectomy. Special attention was given to estab lishing the optimal timing, success rate, and complications of diagnos tic and therapeutic endoscopic retrograde cholangiopancreatography (ER CP) after laparoscopic cholecystectomy. Methods: Fifty-six consecutive patients referred from two major medical centers were evaluated with ERCP after laparoscopic cholecystectomy. The patient population includ ed 22 men and 34 women 16-87 yr of age. Indications included common bi le duct stones seen on operative cholangiography or ultrasound (22), p ersistently elevated liver enzymes and abdominal pain (24), evidence o f biliary injury (9), and other (1). All endoscopic procedures were ca rried out by experienced endoscopists using standard ERCP techniques a nd equipment. Endoscopic papillotomy was performed with 2- to 2.5-cm c utting wire papillotomes and all biliary stones were removed with 8.5- to 14-mm balloons. Small biliary leaks were first treated with 3-7 da ys of nasobiliary drainage, and if persistent with 10-Fr internal sten ts for 1 month. One patient with a biliary stricture was dilated with placement of progressively larger biliary stents over 9-month period, Results: ERCP was performed within 6 h to 2 yr after laparoscopic chol ecystectomy (LC). In 12 patients, it was performed within the first 24 h after LC. A cholangiogram was obtained in all patients. No complica tions were encountered. Thirty patients underwent therapeutic endoscop y. Common bile duct stones were found and were successfully removed fr om 23 patients. One patient required an emergent ERCP and sphincteroto my for gallstone pancreatitis 3 days after LC. Fourteen patients had c ommon bile duct injuries, cystic duct stump leaks (7), or leakage from ducts of Luschka (one patient). All leaks were successfully treated w ith temporary stenting. Six patients with bile duct transection or com plete obstruction by clips required surgical therapy. One patient with a common bile duct stricture was managed with endoscopic stents alone . Two patients had unsuspected malignancies, one each with ampullary a nd pancreatic carcinoma. Fourteen patients had a normal ERCP. Conclusi ons: Diagnostic and therapeutic ERCP can be done within 24 h of LC wit h safety and a high degree of success. Delay in removal of CBD stones may lead to complications. Cystic duct stump leaks are easily correcte d with nasobiliary drainage, and some post-LC strictures may be amenab le to therapy with biliary stents. Finally, malignancy must be exclude d in patients with unexplained recurrent symptoms.