Yield of prospective, noninvasive evaluation of the common bile duct combined with selective ERCP/sphincterotomy in 1390 consecutive laparoscopic cholecystectomy patients

Abstract

The role of noninvasive evaluation of the common bile duct combined with selective preoperative endoscopic retrograde cholangiography and sphincterotomy was prospectively evaluated in 1390 consecutive patients subjected to laparoscopic cholecystectomy. Preoperative common bile duct testing included liver chemistries, transcutaneous ultrasonography, and intravenous cholangiography. When indicated by various sets of abnormal studies, prelaparoscopic endoscopic retrograde cholangiography was attempted in 129 patients (9.3%) and successfully accomplished in 122 (94.6%). Seventy-six patients (62.3%) had duct stones or a papillary stenosis, and 73 of them (96%) were treated successfully by endoscopic duct clearance and subsequent laparoscopic cholecystectomy. No deaths occurred, and the morbidity rate was 6.2% (8/129), including 2 cases of pancreatitis and 1 case of a retained duct stone after sphincterotomy. Predicting the presence of common duct pathology was 60% accurate when based on abnormal laboratory test results alone, 69% when based on abnormal laboratory test results and concomitant radiologic abnormalities, and 42% when based on radiologic criteria alone (p < .05). We conclude that patients with altered serum liver chemistries with or without concomitant positive radiologic criteria should undergo endoscopic cholangiography before laparoscopic cholecystectomy. However, in patients with radiologic duct dilatation as the sole indicator for duct stones, the frequency of normal findings in endoscopic examinations is high. This latter group is probably better managed with intraoperative cholangiography and postlaparoscopic sphincterotomy if needed.