Preoperative versus postoperative endoscopic retrograde cholangiopancreatography in mild to moderate gallstone pancreatitis - A prospective randomized trial

Objective To determine whether endoscopic retrograde cholangiopancreatography (ERCP) and common bile duct (CBD) stone extraction should be performed routinely b efore surgery or selectively after surgery in patients with mild to moderat e gallstone pancreatitis. Summary Background Data The role and timing of ERCP in mild to moderate gallstone pancreatitis rema ins controversial. Routine preoperative ERCP identifies persisting CBD ston es but carries risks of complications and may delay definitive care; Select ive post operative ERCP, performed only if a CBD stone is seen on intraoper ative cholangiography (IOC), avoids unnecessary ERCP but risks unsuccessful stone extraction. Methods A prospective, randomized study of consecutive patients with gallstone panc reatitis was conducted. Using previously determined criteria, patients with acute cholangitis or necrotizing pancreatitis were excluded. Patients cons idered at high risk for persisting CBD stones (CBD size greater than or equ al to 8 mm on admission ultrasound, serum total bilirubin greater than or e qual to 1.7 mg/dL, or serum amylase greater than or equal to 150 U/L on hos pital day 4) were randomly assigned to routine preoperative ERCP followed b y laparoscopic cholecystectomy, or laparoscopic cholecystectomy with select ive postoperative ERCP and endoscopic sphincterotomy only if a CBD stone wa s present on IOC. Primary end points were costs, length of hospital stay, a nd the combined treatment failure rates (failure of diagnostic ERCP and IOC , complications of ERCP and endoscopic sphincterotomy, and complications of surgery). Results One hundred fifty-four consecutive patients with gallstone pancreatitis wer e evaluated prospectively for study eligibility. Sixty patients met the ran domization criteria. Thirty patients were randomized to routine preoperativ e ERCP and 29 patients to selective postoperative ERCP (I patient refused). Age, admission laboratory values, and APACHE II and Imrie scores were simi lar in both groups, By protocol, ERCP was performed in all patients in the preoperative ERCP group. In the postoperative ERCP group, ERCP was necessar y in only 7 of 29 patients (24%). Mean hospital stay was significantly long er in the routine preoperative ERCP group (11.7 days) than in the selective postoperative ERCP group (9.0 days). Mean total cost was higher in the pre operative ERCP group ($9,426) than in the postoperative ERCP group ($7,798) . The combined treatment failure rate was 10% in both groups. Conclusions In patients with mild to moderate gallstone pancreatitis without cholangiti s, selective postoperative ERCP and CBD stone extraction is associated with a shorter hospital stay, less cost, no increase in combined treatment fail ure rate, and significant reduction in ERCP use compared with routine preop erative ERCP.