Selective preoperative endoscopic retrograde cholangiography with sphincterotomy avoids bile duct exploration during laparoscopic cholecystectomy.

A policy of preoperative endoscopic retrograde cholangiography (ERC) for suspected bile duct stones was used in 1507 patients considered for laparoscopic cholecystectomy in three district general hospitals. Altogether 306 patients underwent ERC, and bile duct cannulation was achieved in 276 (90%). Bile ducts were cleared by endoscopic sphincterotomy in 128 of 161 patients (79%) with proven duct stones. Laparoscopic cholecystectomy was completed in 1396 patients. Ten laparotomies were necessary for complications of laparoscopic cholecystectomy. The complication rate for endoscopic sphincterotomy/laparoscopic cholecystectomy was 2.7%, with no mortality. Overall, a combined endoscopic/laparoscopic approach succeeded in 1386 patients (92%). Fourteen patients (1%) had retained stones during a median of 14 months (range 1-42) follow up, all of which were removed by ERC/endoscopic sphincterotomy. If a policy of selective ERC before laparoscopic cholecystectomy is used for all patients with symptomatic gall stones, most will avoid an open operation and laparoscopic exploration of the bile duct is not necessary.     

Diagnostic workup before laparoscopic cholecystectomy--which diagnostic tools should be used?

BACKGROUND/AIMS: A prerequisite for successful laparoscopic cholecystectomy is the exclusion of potential risks such as cholangiolithiasis, anatomical malformations or diseases of the stomach. As there is no general agreement regarding the appropriate preoperative diagnostic workup, we compared different diagnostic methods as to their value in detecting unknown accompanying diseases and complications. METHODOLOGY: Between 9/90 and 8/93, we performed 850 laparoscopic cholecystectomies. The first 700 were included in this study. A prospective comparison was carried out of the diagnostic accuracy of history, physical examination, laboratory tests, upper gastrointestinal endoscopy or barium meal, i.v. cholangiography and abdominal ultrasound. RESULTS: Measurement of the diameter of the common bile duct was found to be a good noninvasive method for diagnosing common bile duct stones (sensitivity 80%, specificity 99%). In combination with the history and the laboratory tests the sensitivity could be improved to 99%. The sensitivity of i.v. cholangiography in detecting common bile duct stones was 80%, the specificity 99.3%. 646/700 patients underwent preoperative endoscopy/barium meal. In 53 (8.2%) patients pathological findings were found, but only in 4 cases (0.6%) they influenced the indication for laparoscopic cholecystectomy. In 1 patient an advanced gastric cancer was diagnosed 6 months after laparoscopic cholecystectomy, the preoperative barium meal did not show any pathological findings. CONCLUSIONS: The results show that routine ultrasonography in combination with history and laboratory tests prior to laparoscopic cholecystectomy can be recommended for detecting common bile duct stones. In patients with 1 or more pathologic finding endoscopic retrograde cholangiopancreatography should be performed preoperatively. A gastroscopy should be done in patients with nonspecific upper abdominal pain, history of peptic ulcer disease and persisting pain after laparoscopic cholecystectomy.     

Laparoscopy in cholecysto-choledocholithiasis

Gallstone disease is one of the most common problems in the gastroenterology and is associated with significant morbidity. It may present as stones in the gallbladder (cholecystolithiasis) or in the common bile duct (choledocholithiasis). At the end of the 1980s laparoscopy was introduced and first laparoscopic cholecystectomy was performed in 1985. The laparoscopic technique for removing the gallbladder is the current treatment of choice, although indications for open surgery exist. To perform laparoscopic cholecystectomy as safe as possible multiple safety measures were developed. The gold standard for diagnosing and removing common bile duct stones is Endoscopic Retrograde Cholangiopancreatography (ERCP). The surgical treatment option for choledocholithiasis is laparoscopic cholecystectomy with common bile duct exploration. If experience is not available, than ERCP followed by elective cholecystectomy is by far the best therapeutic modality. The present review will discuss the use, benefits and drawbacks of laparoscopy in patients with cholecystolithiasis and choledocholithiasis.     

Single-session minimally invasive management of common bile duct stones

Up to 18% of patients submitted to cholecystectomy had concomitant common bile duct stones. To avoid serious complications, these stones should be removed. There is no consensus about the ideal management strategy for such patients. Traditionally, open surgery was offered but with the advent of endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) minimally invasive approach had nearly replaced laparotomy because of its well-known advantages. Minimally invasive approach could be done in either two-session (preoperative ERCP followed by LC or LC followed by postoperative ERCP) or single-session (laparoscopic common bile duct exploration or LC with intraoperative ERCP). Most recent studies have found that both options are equivalent regarding safety and efficacy but the single-session approach is associated with shorter hospital stay, fewer procedures per patient, and less cost. Consequently, single-session option should be offered to patients with cholecysto-choledocholithiaisis provided that local resources and expertise do exist. However, the management strategy should be tailored according to many variables, such as available resources, experience, patient characteristics, clinical presentations, and surgical pathology.     

Technical aspects in the laparoscopic management of complicated common bile duct stones

The management of common bile duct (CBD) stones traditionally required open laparotomy and bile duct exploration. With the advent of endoscopic and laparoscopic technology in the latter half of last century, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) has become the mainstream treatment for CBD stones and gallstones in most medical centers around the world. However, in certain situations, ERCP cannot be feasible because of difficult cannulation and extraction. ERCP can also be associated with potential serious complications, in particular for complicated stones requiring repeated sessions and additional maneuvers. Since our first laparoscopic exploration of the CBD (LECBD) in 1995, we now adopt the routine practice of the laparoscopic approach in dealing with endoscopically irretrievable CBD stones. The aim of this article is to describe the technical details of this approach and to review the results from our series.     

Combination of Preoperative EST,Laparoscopic Cholecystectomy with Choledochotomy,and Postoperative Cholangioscopy in the Treatment of Common Bile Duct Stones

A case of common duct stones, successfully managed with a combination of preoperative EST, laparoscopic choledochotomy and postoperative choledochoscopic stone extraction, is reported. A 32-year-old man was admitted to our hospital because of jaundice and right hypochon-dralgia of several-days' duration. CT, US and ERCP revealed stones in the gallbladder and common bile duct. EST was performed to remove the stones in the common bile duct prior to laparoscopic cholecystectomy. However, the patient developed pancreatitis as a complication of EST, which was successfully managed by conservative therapy. Though some stones remained in the common duct following the first trial of EST, the patient rejected a second round of EST. Laparoscopic cholecystectomy and choledochotomy were performed to remove the gallbladder and the stones remaining in the common bile duct. A T tube was placed in the incised common bile duct for management of possible retained stones. Twenty days after the surgery, successful postoperative cholangioscopy was performed, and the stones remaining in the common duct were removed. Hyperamylasemia and pancreatitis are relatively common complications of EST occurring in about 7% of cases, but only 3% of these patients experience severe pancreatitis, requiring hospitalization. Conservative therapy is always the treatment of choice. In our particular patient, pancreatitis caused by EST was successfully managed by decompression with ENBD and administration of ulinastatin. Residual stones in the CBD were completely removed by laparoscopic common bile duct exploration following EST and postoperative cholangioscopy through the T tube fistula.     

Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique

BACKGROUND: The introduction of laparoscopic cholecystectomy has given rise to a debate as to whether endoscopic retrograde cholangiopancreatography (ERCP) should be performed before or after cholecystectomy in patients with bile duct stones. METHODS: This study evaluated the efficacy of treatment of cholecystocholedocholithiasis in a single step by performing ERCP during surgery in 52 patients (35 women, 17 men; mean age 57.0 years; age range 20 to 89 years). Laparoscopic intraoperative cholangiography via the cystic duct was carried out to confirm the presence of duct stones. A soft-tipped guidewire was passed through the cystic duct and papilla into the duodenum. A papillotome was inserted endoscopically over the guidewire. Endoscopic sphincterectomy was performed and the stones removed with balloon and basket catheters. RESULTS: Endoscopic stone removal was successful in 94% of cases without complications related to ERCP or surgery. Although operative time was lengthened by about 20 minutes, the hospital stay was as short and equal to that for simple laparoscopic cholecystectomy (3 days on average). CONCLUSIONS: The single-step combined endoscopic-laparoscopic technique is safe and effective for treatment of patients with gallbladder and bile duct stones.     

Pre-operative endoscopic ultrasonography can optimise the management of patients undergoing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocholithiasis: a prospective study

BACKGROUND: Pre-operative endosonography has been proposed as a cost-effective procedure in the management of patients who undergo laparoscopic cholecystectomy having an intermediate risk of common bile duct stones. We prospectively evaluated the impact of pre-operative endosonography on the management of patients facing laparoscopic cholecystectomy with abnormal liver function tests as the sole risk factor for choledocolithiasis. METHODS: Among 587 consecutive patients scheduled for laparoscopic cholecystectomy, 47 (8%) patients having one or more abnormal liver function tests but a normal appearance of common bile duct at abdominal ultrasound, underwent pre-operative endosonography. In patients with endosonography-detected common bile duct stones, a pre-operative endoscopic retrograde cholangiography was performed, or an intra-operative endoscopic retrograde cholangiography was scheduled. In all endosonography-negative patients, an intra-operative trans-cystic cholangiography was performed. RESULTS: Endosonography detected common bile duct stones in nine patients (19%) but only in five of them stones were radiologically confirmed (PPV 0.55). Endosonography-detected stones were confirmed in four of four (100%) patients in whom cholangiography was performed within 1 week, but only in one of five (20%) patients in whom radiology was further delayed (P < 0.05). In three of four cases (75%), stones detected at endosonography but not confirmed at X-rays, were smaller than 2.0 mm. Among 38 patients with negative endosonography, common bile duct stones were found in two patients (NPV 0.95), whereas unplanned endoscopic stone extraction was needed only in one patient (NPV 0.97). CONCLUSIONS: Pre-operative endosonography can spare unnecessary pre-operative endoscopic retrograde cholangiography as well as inappropriate scheduling of intra-operative endoscopic retrograde cholangiography in patients undergoing laparoscopic cholecystectomy with abnormal liver function tests. To maximise the impact of endosonography on the management of these patients, the procedure should be performed immediately before laparoscopic cholecystectomy.     

The case for laparoscopic common bile duct exploration

The modern surgeon's approach to choledocholithiasis depends his or her view of cholangiography. During the early 1990 there was a swing away from cholangiography, which had previously been common practice. This was because of perceptions of difficulty with the technique, the time it took, and perhaps an implied increase in costs because of the time factor. There was no evidence on which to base this decision. This led to a marked upswing in the use of endoscopic retrograde cholangiopancreatography (ERCP). There were a large number of ERCPs with normal results performed prior to laparoscopic cholecystectomy. This paper states the case for intraoperative cholangiography and common bile duct clearance at the time of cholecystectomy. It is hoped that this technique will be adopted so patients can undergo a single procedure to remove their gallstones and common bile duct stones if they exist and to decrease the incidence of normal preoperative ERCPs and the need for a second procedure postoperatively to clear stones if they are found.     

Choledocholithiasis： Evolving standards for diagnosis and management

Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecys-tectomy will have common bile duct (CBD) stones. CBD stones may be discovered preoperatively, intraop-eratively or postoperatively Multiple modalities are available for assessing patients for Choledocholithiasis including laboratory tests, ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancrea-tography (MRCP). Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intra-operative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is often dictated by the clinical situation.     

三种外科疗法治疗老年胆囊结石并发肝外胆管结石病人的疗效比较

目的探讨3种外科疗法治疗老年胆囊结石并发肝外胆管结石病人的疗效与并发症。方法选取我院2016年7月至2019年6月收治的178例胆囊结石并发肝外胆管结石的老年病人作为研究对象,其中63例采用腹腔镜胆囊切除术联合腹腔镜胆总管探查术(LC+LCBDE),61例采用内镜逆行胰胆管造影联合腹腔镜胆囊切除术(ERCP+LC),54例采用胆囊切除术联合胆总管探查术(OC+OCBDE),对3种术式治疗前后病人的肝功能、手术情况及并发症发生情况进行比较分析。结果3组病人术后5 d AST、ALT以及总胆红素等肝功能指标均较术前明显降低(P<0.05);3组肝功能差异无统计学意义(P>0.05)。OC+OCBDE组手术时间较LC+LCBDE组和ERCP+LC组明显缩短(P<0.05),OC+OCBDE组术中出血量、肛门排气时间以及住院时间均较LC+LCBDE组和ERCP+LC组明显增加(P<0.05)。LC+LCBDE组、ERCP+LC组和OC+OCBDE组术后并发症的发生率分别为7.94%、21.31%和25.93%,组间比较差异具有统计学意义(P<0.05)。结论3种外科疗法治疗胆囊结石并发肝外胆管结石均可有效清除结石,改善肝功能,其中OC+OCBDE术式在缩短手术时间上具有一定的优势,LC+LCBDE术式发生术后并发症的风险最小。     

内镜扩约肌切开术治疗胆总管继发性结石

目的评价逆行胰胆管造影术（ＥＲＣＰ）和内镜括约肌切开术（ＥＳＴ）在腹腔镜胆囊切除前后诊断和治疗胆总管继发结石中的作用．方法采用ＥＲＣＰ和ＥＳＴ在ＬＣ术前或术后诊断和治疗胆总管继发结石２２８例,其中包括ＬＣ术前发现的１８５例和术后确诊的４３例．常规ＥＲＣＰ检查,证实胆总管内有结石后行ＥＳＴ．然后根据结石形态、大小和数目不同采取不同方法处理结石．①自然排石,适合于直径在０３ｃｍ～０８ｃｍ的结石;②取石网篮取石,适合于直径在０９ｃｍ～１５ｃｍ的结石;③碎石篮碎石,适宜直径大于１５ｃｍ以上的结石．结果全部２２８例患者中,ＥＳＴ成功２１７例（９５２％）,胆总管结石完全排出２０９例（９１７％）,发生各种并发症１９例（８８％）,主要并发症为急性胰腺炎、急性胆管炎和Ｏｄｄｉ扩约肌切口渗血,全部经非手术治疗愈合,无死亡病例．结论ＥＲＣＰ和ＥＳＴ是ＬＣ术前和术后诊治胆总管结石安全有效的方法之一．     

Cystic Duct Stones Detected During Intraoperative Cholangiography in Laparoscopic Cholecystectomy

During intraoperative cholangiography, cystic duct stones were diagnosed in 79 of 898 consecutive patients (8.8%) who underwent laparoscopic cholecystectomy over a 45-month period. The stones were successfully removed laparoscopically. In addition, it should be mentioned that the stones were identified and retrieved before the cholangiography was started in all but 8 of the 79 cases. Of these 79, only 27 cases (34.2%) had been diagnosed as having cystic duct stones preoperatively by intravenous cholangiography and/or endoscopic retrograde cholangiography. From the results obtained, it can be concluded that intraoperative cholangiography is mandatory to detect unsuspected retained stones not only in the common duct but also in the cystic duct during laparoscopic cholecystectomy, and also provides vital information as to biliary anatomic variations, the proximity of the cystic duct to the common duct, and the confirmation of inadvertent bile duct injury.     

Echo-endoscopy versus endoscopic retrograde cholangiography for the diagnosis of choledocholithiasis: the influence of the size of the stone and diameter of the common bile duct

BACKGROUND: Endoscopic retrograde cholangiography is highly accurate in diagnosing choledocholithiasis, but it is the most invasive of the available methods. Endoscopic ultrasonography is a very accurate test for the diagnosis of choledocholithiasis with a risk of complications similar to that of upper gastrointestinal endoscopy. AIM: To compare the accuracy of endoscopic ultrasonography and endoscopic retrograde cholangiography in the diagnosis of common bile duct stones before laparoscopic cholecystectomy and to analyze endoscopic ultrasound results according to stone size and common bile duct diameter. PATIENTS AND METHODS: Two hundred and fifteen patients with symptomatic gallstones were admitted for laparoscopic cholecystectomy. Sixty-eight of them (31.7%) had a dilated common bile duct and/or hepatic biochemical parameter abnormalities. They were submitted to endoscopic ultrasonography and endoscopic retrograde cholangiography. Sphincterotomy and sweeping of the common bile duct were performed if endoscopic ultrasonography or endoscopic retrograde cholangiography were considered positive for choledocholithiasis. After sphincterotomy and common bile duct clearance the largest stone was retrieved for measurement. Endoscopic or surgical explorations of the common bile duct were considered the gold-standard methods for the diagnosis of choledocholithiasis. RESULTS: All 68 patients were submitted to laparoscopic cholecystectomy with intraoperative cholangiography with confirmation of the presence of gallstones. Endoscopic ultrasonography was a more sensitivity test than endoscopic retrograde cholangiography (97% vs. 67%) for the detection of choledocholithiasis. When stones >4.0 mm were analyzed, endoscopic ultrasonography and endoscopic retrograde cholangiography presented similar results (96% vs. 90%). Neither the size of the stone nor the common bile duct diameter had influence on endoscopic ultrasonographic performance. CONCLUSIONS: For a group of patients with an intermediate or moderate risk with respect to the likelihood of having common bile duct stones, endoscopic ultrasonography is a better test for the diagnosis of choledocholithiasis when compared to endoscopic retrograde cholangiography mainly for small-sized calculi.     

Value of magnetic resonance cholangiography in the preoperative diagnosis of common bile duct stones

OBJECTIVE: The aim of this study was to assess the performance of magnetic resonance cholangiography (MRC) in the preoperative diagnosis of choledocholithiasis. METHODS: A total of 147 consecutive patients underwent MRC for clinical and biological signs of common bile duct stones. ERCP was then carried out in 101 patients in whom there was a past history of cholecystectomy. The remaining 46 patients without a past history of biliary surgery underwent cholecystectomy and intraoperative cholangiography (IOC). The diagnosis obtained by MRC was compared with the final diagnosis established after endoscopic or surgical removal of calculi. RESULTS: A total of 113 patients had choledocholithiasis (single or multiple, including 15 cases of microlithiasis). There were no false-positive results with MRC. The false-negative results were caused mainly by small stones <3 mm in diameter, and to a lesser extent, cholangitis. Overall, the sensitivity was 93% and the specificity 100% for MRC in detecting common bile duct stones. The sensitivity and specificity of ERCP were respectively 94% and 100%, versus 93.5% and 93.3% for IOC. There was no statistically significant difference, however, between MRC and the other techniques. CONCLUSION: MRC is a key technique in the preoperative diagnosis of choledocholithiasis. Its diagnostic value is comparable to ERCP, but it appears to be more specific than IOC. Nevertheless, its diagnostic capability remains limited in cases of microlithiasis and cholangitis.     

Surgery in biliary lithiasis: from the traditional"open" approach to laparoscopy and the"rendezvous" technique

BACKGROUND:According to the current literature, biliary lithiasis is a worldwide-diffused condition that affects almost 20% of the general population. The rate of common bile duct stones (CBDS) in patients with symptomatic cholelithiasis is estimated to be 10% to 33%, depending on patient's age. Compared to stones in the gallbladder, the natural history of secondary CBDS is still not completely understood. It is not clear whether an asymptomatic choledocholithiasis requires treatment or not. For many years, open cholecystectomy with choledochotomy and/or surgical sphincterotomy and cleaning of the bile duct were the gold standard to treat both pathologies. Development of both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic surgery, together with improvements in diagnostic procedures, influ-enced new approaches to the management of CBDS in associ-ation with gallstones. DATA SOURCES: We decided to systematically review the lit-erature in order to identify all the current therapeutic options for CBDS. A systematic literature search was performed in-dependently by two authors using PubMed, EMBASE, Scopus and the Cochrane Library Central.RESULTS: The therapeutic approach nowadays varies great-ly according to the availability of experience and expertise in each center, and includes open or laparoscopic common bile duct exploration, various combinations of laparoscopic cholecystectomy and ERCP and combined laparoendoscopic rendezvous. CONCLUSIONS: Although ERCP followed by laparoscopic cholecystectomy is currently preferred in the majority of hospitals worldwide, the optimal treatment for concomitant gallstones and CBDS is still under debate, and greatly varies among different centers.     

经内镜鼻胆管引流术在腹腔镜胆管探查中的作用

目的：应用经内镜鼻胆管引流术(ENBD)作为腹腔镜胆管探查术(LCBDE)胆管引流方式，探讨其应用价值。方法：对拟行腹腔镜下胆管探查的患者术前进行ENBD，后经胆总管探查切口应用液电碎石、胆道镜取石，将肝内外胆管结石取净，保留鼻胆管于胆管内，将胆总管探查切口一期缝合，常规放置腹腔引流管。术后经鼻胆管造影，肝内外胆管无残余结石，无胆漏，择期拔除腹腔引流管及鼻胆管。结果：共43例患者术前行ENBD，平均6．1d后行LCBDE。36例(83.7％)患者成功进行LCBDE，胆管探查切口一期缝合。术后经鼻胆管造影，发现1例(2．6％)术中胆道镜漏诊--小结石，经内镜取石后痊愈；无胆管狭窄及胆漏等并发症发生。另有7例患者(18．6％)中转开腹手术，其中2例保留鼻胆管，胆管切口行一期缝合，术后顺利拔除鼻胆管。38例患者(88．4％)均成功应用：ENBD进行胆管引流，平均3．2d拔除腹腔引流管，6.7d拔除鼻胆管，无相关并发症发生。结论：ENBD作为LCBDE胆管引流，是安全有效的方式，且术后引流时间短，并发症少，可充分发挥出腹腔镜治疗胆管结石微创的优势。     

Management of unsuspected common bile duct stones found during laparoscopic cholecystectomy by means of transcystic catheter placement and papillary dilation

BACKGROUND: The optimal treatment strategy for treatment of bile duct stones first diagnosed during laparoscopic cholecystectomy has not been established. We prospectively treated unsuspected bile duct stones by means of intraoperative placement of a transcystic catheter followed by postoperative pharmacologic papillary dilation or endoscopic papillary balloon dilation. METHODS: In 17 patients with bile duct stones first found at laparoscopic cholecystectomy, a catheter was introduced via the cystic duct into the bile duct. If postoperative cholangiography via a transcystic catheter showed stones 5 mm or less in diameter, glyceryl trinitrate was infused via the catheter into the bile duct. Patients in whom medical dilation was unsuccessful or who had larger stones underwent endoscopic papillary balloon dilation. RESULTS: Stone diameter measured 3 to 11 mm (mean 6.4 mm). Postoperative cholangiography revealed spontaneous passage in four patients. After pharmacologic papillary dilation, two of five patients with stones 5 mm or less in diameter had stone clearance. The remaining 11 patients underwent successful endoscopic papillary balloon dilation with stone clearance. In two patients, a guidewire introduced via a transcystic catheter through the papilla facilitated selective biliary cannulation. One early minor complication occurred. All patients remained without symptoms for a mean follow-up of 13 months. CONCLUSION: For unsuspected bile duct stones (usually small ones), this strategy is a simple and effective alternative to laparoscopic bile duct exploration and postoperative sphincterotomy and may minimize early and late complications. Transcystic catheterization ensures access to the bile duct, thereby avoiding endoscopic treatment failures.     

Endoscopic retrograde cholangiography and laparoscopic cholecystectomy: stones,stents and sphincterotomy

Endoscopic retrograde cholangiopancreatography (ERCP) is clearly a useful adjunct in the management of patients undergoing laparoscopic cholecystectomy who have common bile duct stones. Whether endoscopic sphincterotomy plus laparoscopic cholecystectomy is superior to traditional open cholecystectomy and bile duct exploration is a question which remains to be answered by prospective, randomized trials. The immense popularity of laparoscopic cholecystectomy may prohibit such a study in the USA. In expert hands, endoscopic stone extraction is usually successful, so ERCP can be deferred until after cholecystectomy unless there is serious suspicion of a duct stone preoperatively. Actual clinical practice will depend, however, on the skill of the surgeon, the skill of the endoscopist, and the commitment to removing the gallbladder laparoscopically. It would seem prudent for surgeons to continue to direct their energy toward conquering the common bile duct via the laparoscope, and leave ERCP and stone extraction in the realm of the endoscopist who has been extensively trained in this difficult technique. Proficiency at ERCP, sphincterotomy and stone extraction requires considerable training, and the procedure should not be attempted by individuals who have performed fewer than 100 ERCPs and 25 individually supervised sphincterotomies, according to the ASGE Standards of Training 1992. As experience with video endoscopic surgery increases and technology improves, it will become possible to remove most duct stones at the time of cholecystectomy, thus obviating the need for endoscopic sphincterotomy.In addition, ERCP should be regarded as the treatment of choice for postoperative cystic duct stump leaks. Studies have shown that any type of biliary decompression, i.e. sphincterotomy, stents or nasobiliary catheters, will be successful. The authors recommend that, in the absence of duct stones, stenting or nasobiliary catheters be used as they are less invasive. Bile duct leaks may also be managed endoscopically, but success depends on the individual characteristics of the duct injury. The decision to manage late onset strictures endoscopically should be individualized, and consideration of local endoscopic expertise, operative risk, interval between surgery and stricture, and the patient's wishes should be made.     

Role of ERCP and Therapeutic Biliary Endoscopy in Association with Laparoscopic Cholecystectomy

Laparoscopic removal is rapidly becoming the preferred method of cholecystectomy; however, choledocholithiasis cannot usually be managed with a laparoscopic approach. Combined endoscopic sphincterotomy and laparoscopic cholecystectomy is a potential solution to this problem. To determine the feasibility of this combined procedure we studied 41 patients who had both endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy. Indications for ERCP included jaundice, gallstone pancreatitis, dilated ducts on sonography, elevated liver enzymes, or stones seen on operative cholangiography. Twenty-eight patients had ERCP preoperatively. Nine patients had common duct stones; these were successfully removed from eight patients after sphincterotomy. Two patients had unexpected strictures requiring a change in surgical approach. Thirteen patients had ERCP postoperatively. Eight of those patients had common duct stones, and all were successfully removed following endoscopic sphincterotomy. Three patients had postoperative strictures, one of which was treated by endoscopic stent placement. No complications as a result of ERCP or sphincterotomy were encountered. ERCP and endoscopic sphincterotomy can be safely performed both preoperatively and as early as 1 day postoperatively. If indicators of choledocholithiasis are present, preoperative ERCP is preferred, because stone removal occasionally is unsuccessful, and cholangiographic findings may change the operative approach. Postoperative ERCP can define and, in some instances, treat biliary tract injuries resulting from laparoscopic cholecystectomy.