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WJOLS

Laparoscopic Cholecystectomy after Endoscopic Retrograde Cholangiopancreatography: The Optimal Timing for Operation

significantly prolonged among patients in the group II Endoscopic retrograde cholangiopancreatography
(4 ± 2 days) vs (2.5 ± 1.5 days) in group I. remains the preferred approach at most centers for mana-
One patient had cystic stump leakage after LC, for which ging patients with suspected CBD stones. However, ERCP is
postoperative endoscopic intervention and stent placement associated with complications such as pancreatitis, hemorr-
was done. This patient did recover completely. Another hage, cholangitis, duodenal perforation (5 to 11%) and
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patient had postoperative blood collection in gallbladder mortality of up to 1%. Moreover, failure rates of 5 to 10%
bed and percutaneous pigtail catheter drainage was carried are reported with ERCP. In the present study, mild post-
out. Otherwise, the complications in all groups were minor, ERCP pancreatitis occurred in five patients (6.7%); all of
and responded well to conservative management. During them were treated successfully with conservative treatment.
the follow-up period, no biliary symptoms appear in both In addition, when patients proceed to ERCP, a significant
groups. number of them may not have stones. 21,22 ERCP should
be performed only in patients who are expected to require
dISCuSSIOn an intervention; it is not recommended for use solely as a
The last 30 years have seen major developments in the diagnostic test. 23
management of gallstone-related disease. ERCP has Previous studies have shown that LC after ES is more diffi-
become a widely available and routine procedure, whilst open cult than LC for uncomplicated cholelithiasis: the conversion
cholecystectomy has largely been replaced by a laparo - rate after a previous ES has been reported to be as high as
s copic approach, which may or may not include laparoscopic 8 to 55% vs lower than 5% in patients with uncomplicated

exploration of the common bile duct (LCBDE). In addition, disease. 4,8,9,24-28 In this study, the conversion rates to an open
new imaging techniques such as magnetic resonance cholan- procedure were 6.6 and 10.6% in groups I and II respectively.
giography (MRC) and endoscopic ultrasound (EuS) offer It might be beneficial to have these patients operated on by
the opportunity to accurately visualize the biliary system an experienced laparoscopic surgeon to minimize the risk
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without instrumentation of the ducts. 1,10 of conversion and subsequent morbidity. The etiology
Choledocholithiasis is concomitant with gallstones in is thought to be because of disruption of the sphincter of
approximately 3 to 20% of the patients. 11-16 In the pre- Oddi and subsequent bacterial colonization of the biliary
endoscopy and prelaparoscope era, the standard treatment for tract leading to inflammation and subsequent scarring of
patients suffering from gallstones accompanied with CBD the hepatoduodenal ligament hindering dissection of Calot’s
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stones was open cholecystectomy and CBD exploration. triangle. This theory of reflux and bacterial colonization is
Currently, open choledochotomy could still play a role in strengthened by the finding that bile in patients who have
those cases with an intraoperative unexpected diagnosis of undergone a sphincterotomy is colonized in approximately
choledocholithiasis, with CBD dilatation or where all other 60% of patients. 30,31
endoscopic, percutaneous and laparoscopic approaches The technique of combined LC with intraoperative
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failed. However, open CBD exploration remains the ERCP as a single-step procedure implies some organi-
‘gold standard’ for selected rare patients, such as those with zational problems concerning the availability of an endoscopic
Mirizzi syndrome, Billroth II anatomy, and those requiring a setting and experienced endoscopist in the operating theater
drainage procedure. 18,19 A Roux-en-Y hepaticojejunostomy, whenever needed. Performing ERCP after surgery would
a choledochojejunostomy, or a surgical sphincteroplasty raise the dilemma of managing CBD stones whenever ERCP
may be indicated for sphincter of Oddi stenosis/dysfunction, fails to retrieve them because a third procedure would then
primary CBD stones, patients with duodenal diverticula, be needed. 1,32,33 Sequential treatment, ES followed by early
multiple stones or intrahepatic stones. 10 elective LC, is a safe procedure, and should be considered
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With the advent of laparoscopic and endoscopic as a standard, definitive treatment for CCL.
techniques, several alternative treatments have been deve- Laparoscopic cholecystectomy should be performed soon
lo ped to treat CCL. An interesting observational study from after ES; surgery could be easier if performed early before
Sweden reported a so-called ‘paradigm shift’ from open inflammatory process sets in. This study revealed that the
choledochotomy and cholecystectomy toward bile duct first group stayed in the hospital for a shorter time than the
clearance using the endoscopic route and selective LC in second group (2.5 ± 1.5 vs 4 ± 2 days). This difference in the
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patients suffering from CCL. Cholecystectomy is recom- length of stay was statistically significant (p = 0.001). Such
mended for all patients with CBD stones and symptomatic a longer stay will possibly lead to increased cost of health
gallbladder stones, unless there are specific reasons for services and could lead to increased incidence of hospital
1
considering surgery inappropriate. acquired infections. If early LC for acute cholecystitis is
World Journal of Laparoscopic Surgery, May-August 2014;7(2):69-73 71