THE ROLE OF ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAM IN LAPAROSCOPIC CHOLECYSTECTOMY

Four hundred and fifty-nine patients were studied to evaluate the role of diagnostic and therapeutic endoscopic retrograde cholangio-pancrea ticrogram (ERCP) in their management before laparoscopic cholecystecto my (LC) when choledocholithiasis is suspected. Using bilirubin, liver function tests (LFTs) (alkaline phosphatase, SGOT, SGPT) and findings on ultrasound of a dilated common bile duct (CBD), 37 patients (8.1%) were suspected of having concomitant common bile duct stones preoperat ively. These patients were subjected to the following diagnostic and t herapeutic procedures: 25 ERCPs, 20 laparoscopic cholangiograms, and t hree extracorporeal shock wave lithotripsies. Preoperative ERCP was do ne on 1.9 patients, intraoperative ERCP-sphincterotomy was done on one patient, and postoperative ERCP-sphincterotomy was done on five patie nts. Fifteen laparoscopic cholangiograms were done as primary tests an d five after preoperative ERCP. Sixteen patients (3.5%) had stones in their CBD. Four patients had their laparoscopic cholecystectomy cancel led, and one patient had laparoscopic common duct exploration that was converted to an open procedure. Three groups were identified: group I , patients with a high index of suspicion, included elevated bilirubin with elevation of all three LFTs, or normal bilirubin with elevation of all three LFTs with or without dilated CBD. Seventy-five per cent o f this group had CBD stones. Group II, patients with a low index of su spicion, included normal bilirubin and normal CBD by ultrasound with e levation of the alkaline phosphatase alone or elevation of two of the three LFTs. Six per cent of this group had CBD stones. Group III, pati ents with no index of suspicion, were patients with normal preoperativ e laboratory test results and CBD. Two patients (0.47%) in this group had elevated LFTs postoperatively. Only one of them required ERCP-endo scopic sphincterotomy and extracorporeal shockwave lithotripsy. An alg orithm was developed after analyzing our results.