Endoscopic retrograde cholangiopancreatography and laparoscopic cholecystectomy.

Endoscopic retrograde cholangiopancreatography (ERCP) is a useful adjunct to laparoscopic cholecystectomy. Preoperative ERCP is indicated if there is a high degree of suspicion for common duct stones, when severe gallstone-induced pancreatitis is present, or when there is uncertainty regarding the diagnosis. The best indicators of common duct stones preoperatively are an elevated bilirubin, a dilated common bile duct (CBD) on sonography, or stones visualized in the CBD on sonography. Mild gallstone pancreatitis and transient mild elevations in liver enzymes are not predictive of CBD stones and are not indications for ERCP. Postoperative ERCP is highly effective in clearing CBD stones. It has the advantage of being more readily available as compared to laparoscopic CBD exploration, and preserves all the advantages of the laparoscopic approach. Post-operative ERCP is indicated for retained CBD stones, evaluation and therapy of biliary injuries, and persistent biliary symptoms or abnormal liver enzymes and bilirubin. ERCP is the procedure of choice for the evaluation of laparoscopic biliary injuries. Major biliary injuries will generally require surgical therapy. Bile duct strictures are sometimes amenable to endoscopic therapy with dilation and stents. Biliary leaks are readily treatable with endoscopic therapy. Small cystic duct stump leaks and leaks from a duct of Lushka close within a few days with nasobiliary drainage. Larger leaks may require more prolonged drainage with stents and early supplemental percutaneous drainage of an accompanying biloma. Bilious ascites should be treated with nasobiliary drainage using low suction to be prevent contamination of the peritoneal cavity with intestinal flora, and simultaneous percutaneous ascites drainage. Biliary leaks, unless associated with major bile duct injuries, rarely require surgical therapy.