Intraoperative ERCP during laparoscopic cholecystectomy for patients with symptomatic cholecystolithiasis and suspected choledocholithiasis but failed preoperative ERCP

Background and study aims: Preoperative ERCP and EST with stone extraction is the gold standard therapy for symptomtic cholecystolithiasis and suspected choledocholithiasis. However, if initial ERCP fails, performing intraoperative ERCP during laparascopic cholecystectomy may be an alternative therapeutic option.

Patients and methods: Out of 1650 ERCP procedures intraoperative ERCP was performed in 5 consecutive patients, in whom preoperative ERCP and selective bile duct cannulation failed. All patients were hospitalized due to symptomatic cholecystolithiasis and clinical signs of biliary obstruction. The cannulation failure was due to juxtapapillary diverticulum (2 pts), suprapapillary stone impactation (2 pts), and Vater papilla stenosis (1 pt). Intraoperative ERCP was performed using the rendezvous technique. Firstly, the transcystic guide wire introduced through the common bile duct anterogradely that was grasped with a snare and pulled through the duodenoscop. Next, a double lumen sphincterotome was advanced over the guide wire to facilitate bile duct cannulation and to perform EST, followed by bile duct clearance with a Dormia basket. All patients underwent intraoperative cholangiography to document stone free status of the CBD. Finally, the cystic duct was closed and the surgeon proceeded with laparoscopic cholecystectomy.

Results: Intraoperative ERCP, EST and complete bile duct clearance was successful in all 5 patients. Mild post-ERCP pancreatitis observed after the pre-operative and failed ERCP in two patients. In contrary, no post-procedure morbidity occurred after the combined approach. The average time increase of surgery was 20 minutes.

Conclusions: Intraoperative ERCP can be suggested as useful alternative therapeutic approach in patients with symptomatic cholecystolithiasis and biliary obstruction in whom preopeartive ERCP failed. The advantage of intraoperative ERCP are: less morbidity (lower risk of post-ERCP pancreatitis), a shorter total hospital stay, and reduced costs.