The role of endoscopic retrograde cholangiopancreatography with laparoscopic cholecystectomy in the management of choledocholithiasis.

Perioperative endoscopic retrograde cholangiopancreatography (ERCP) and sphincterotomy (ES) offer the ability to remove common bile duct stones (CBDS) and still use the laparoscopic technique for cholecystectomy. The accuracy of predicting choledocholithiasis has been variable in several studies. The indications and complications of perioperative ERCP and ES with laparoscopic cholecystectomy (LC) are presented here. Between 6/1/90 and 11/11/93, 484 LC were performed at Santa Barbara Cottage Hospital. A total of 38 patients underwent perioperative ERCP; 33 patients underwent preoperative ERCP with 3/33 (9%) failing to cannulate the ampulla; 15 patients had choledocholithiasis; and 14/15 (93%) were cleared by ES. Fifteen patients had a normal CBD on ERCP. There were no deaths in this group of patients, seven of 38 (18%) had complications, including bleeding and post ERCP hyperamylasemia. Patients who had a normal CBD and underwent preoperative ERCP (9/15, 60%) had a history of gallstone pancreatitis or hyperamylasemia that was resolved or resolving before ERCP. Patients without stones on ERCP or cholangiogram (11/15, 73%) had a normal bilirubin (avg. 1.0 mg/dL; Range 0.4-2.3). Patients with choledocholithiasis (8/15, 53%) had a history of jaundice or elevated bilirubin before ERCP (avg. 2.59 mg/dL; range 0.2-9.3). ERCP with ES and laparoscopic cholecystectomy is a safe and effective method for the management of symptomatic cholelithiasis with choledocholithiasis. A history of gallstone pancreatitis or hyperamylasemia that is resolving or resolved in the absence of an elevated bilirubin does not require preoperative ERCP before LC with cholangiogram.