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Surgical Endoscopy

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31-07-2023 | Endoscopic Retrograde Cholangiopancreatography | 2023 SAGES Oral

ERCP findings provide further justification for a “surgery-first” mindset in choledocholithiasis

Authors: Gloria Sanin, Gabriel Cambronero, James Patterson, Maggie Bosley, Aravindh Ganapathy, Carl Wescott, Lucas Neff

Published in: Surgical Endoscopy | Issue 11/2023

Abstract

Introduction

Choledocholithiasis is most often managed in a two-procedure pathway including endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, surgery-first approach consisting of LC, cholangiogram, and laparoscopic common bile duct exploration (LCBDE) is associated with reduced hospital stays and equivalent morbidity. Despite this, nationwide referral patterns heavily favor ERCP, obscuring those undergoing ERCP with obstructions amenable to simple intraoperative interventions. We hypothesized that most patients had endoscopic findings consistent with simple sludge or small-to-medium stones, which could have been cleared by basic LCBDE maneuvers.

Methods

We retrospectively reviewed 294 patients > 18 years old who underwent preoperative ERCP for the management of suspected choledocholithiasis. Exclusion criteria included: failed ERCP, cholangitis, prior cholecystectomy, patient refusal of surgery, or medical conditions precluding surgical candidacy. Stone size was categorized as small (0–4 mm), medium (5–7 mm), and large (≥ 8 mm).

Results

At the time of ERCP, 37 (20.1%) patients had sludge only, 96 (52.2%) had stones only, 42 (22.8%) had sludge and stones, and 9 (4.8%) had no stones. Of the 138 patients with any stones, 37 (26.8%) had small stones, 41 (29.7%) medium, 43 (31.2%) large, and 17 (12.3%) had uncharacterizable stones. Overall, 74.3% of patients had findings of sludge, stones (0–7 mm), or negative ERCP.

Conclusion

The majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had findings that are amenable to simple intraoperative interventions. In fact, over a quarter of the patients had a negative ERCP, sludge, or small stones which would likely be cleared by flushing/glucagon precluding any further instrumentation. While large stones may require more advanced techniques, this represents a small percentage of patients. Surgery-first management for suspected choledocholithiasis can offer an efficient alternative for the majority of patients.

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Title: ERCP findings provide further justification for a “surgery-first” mindset in choledocholithiasis
Authors: Gloria Sanin
Gabriel Cambronero
James Patterson
Maggie Bosley
Aravindh Ganapathy
Carl Wescott
Lucas Neff
Publication date: 31-07-2023
Publisher: Springer US
Keywords: Endoscopic Retrograde Cholangiopancreatography
Choledocholithiasis
Cholecystectomy
Cholangitis
Published in: Surgical Endoscopy / Issue 11/2023
Print ISSN: 0930-2794
Electronic ISSN: 1432-2218
DOI: https://doi.org/10.1007/s00464-023-10329-x

Keynote webinar | Spotlight on medication adherence

Springer Medicine

ERCP findings provide further justification for a “surgery-first” mindset in choledocholithiasis

Abstract

Introduction

Methods

Results

Conclusion

Keynote webinar | Spotlight on medication adherence

Springer Medicine

Abstract

Introduction

Methods

Results

Conclusion

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