Routine intravenous cholangiography, selective ERCP and endoscopic treatment of bile duct stones before laparoscopic cholecystectomy

Background: No procedure has yet been identified as the standard for the de tection and management of choledocholithiasis in patients undergoing laparo scopic cholecystectomy. Methods: A prospective study involved 1305 patients undergoing elective lap aroscopic cholecystectomy. Intravenous cholangiography was performed on all patients except those with jaundice or cholangitis, acute pancreatitis, or allergy to contrast material. Patients underwent endoscopic retrograde cho langiography (ERC) and endoscopic sphincterotomy when there was a strong su spicion of choledocholithiasis, positive or inconclusive findings on intrav enous cholangiography or allergy to contrast material with signs of possibl e choledocholithiasis. intraoperative cholangiography was performed when pa tients did not undergo ERC or intravenous cholangiography and whenever the surgeon was in doubt about biliary anatomy or biliary clearance. Results: Two hundred thirty-one patients (17.7%) were referred for preopera tive ERC; 14 of them were referred for open surgery because of failure of E RC or sphincterotomy. Only 54 patients underwent intraoperative cholangiogr aphy. Bile duct stones, detected in 186 cases (14.2%) (68 of which were asy mptomatic), were removed before surgery in 162 cases (87.1%) and during sur gery in 20 (10.7%). Self-limited pancreatitis occurred in 3.6% of the patie nts after sphincterotomy. Laparoscopic cholecystectomy was performed in 98. 7% of the cases. The conversion rate was 8% if sphincterotomy had been perf ormed previously, and 3% after standard laparoscopic cholecystectomy (p < 0 .001). The morbidity rate was 5% and the mortality rate 0.08%. During the f ollow-up period 4 patients had retained stones that were treated endoscopic ally. Conclusions: Preoperative ERC followed by laparoscopy is the best approach to treatment of patients with cholecystolithiasis and suspected choledochol ithiasis.