LAPAROSCOPIC CHOLECYSTECTOMY AND COMMON BILE-DUCT STONES - THE UTILITY OF PLANNED PERIOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY AND SPHINCTEROTOMY - EXPERIENCE WITH 63 PATIENTS

Objective Planned perioperative endoscopic retrograde cholangiography (ERC) and sphincterotomy (ES) for suspected or proven common bile duct stones (CBDS) has been attempted in 63 of 540 consecutive patients un dergoing laparoscopic cholecystectomy (LC). Experience with this inter vention has been studied with respect to accuracy, efficacy, and safet y. Summary Background Data The optimal management of CBDSs in the era of LC is not defined. Methods exist for the laparoscopic manipulation of the common bile duct; however, experience is limited. Until surgeon s become comfortable with this more demanding technique, ERC and ES wi ll have a prominent role in the perioperative management of CBDSs. Met hods A preoperative group (n = 41) included all candidates for LC with historical, biochemical, or radiologic evidence of CBDSs. A postopera tive LC group (n = 22) included patients with stones diagnosed by intr aoperative cholangiogram (IOC) (n = 6) or with signs or symptoms of re tained, but unproven, CBDSs (n = 16). Results Thirty-six (88%) of the preoperative attempts were successful. Stones were identified in 18 ca ses and ES and duct clearance were achieved in all 18. In the postoper ative group, ERC was successful in 21 (95%) cases. Calculi were demons trated in 5 of 6 patients with a positive IOC and 6 of 16 with clinica lly suspected retained stones. ES and duct clearance were achieved in all 11 patients with documented CBDSs. Overall, ERC was accomplished i n 90% of cases. Stones were identified in 51% of cases and all stones were cleared by ES. Morbidity was confined to four cases of self-limit ed pancreatitis (6%). There were no deaths. Conclusions The perioperat ive management of CBDSs is an appealing approach for patients anticipa ting the benefits of LC, at least until the laparoscopic manipulation of the common bile duct becomes a more widely accepted technique.