Selection criteria for preoperative endoscopic retrograde cholangiopancreatography in the laparoscopic era.

BACKGROUND

Indicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography.

OBJECTIVE

To refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP).

DESIGN

Retrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy.

SETTING

Two ERCP units in adjacent teaching hospitals.

PATIENTS: Three hundred seventeen patients with gallstones and in situ gallbladders.

INTERVENTION: Common bile duct imaging at ERCP.

MAIN OUTCOME MEASURES: Abnormalities justifying ERCP.

RESULTS

Abnormalities justifying ERCP were found in 66% of patients. This group differed significantly from those with normal ducts, with more being referred with abnormal results of all liver function tests (P < .001), jaundice (P < = .001), a dilated CBD on ultrasound (P < .001), or CBD stones on ultrasound (P < .001). On the other hand, patients with normal ducts were significantly more likely to have been referred with pancreatitis (P = .003) or elevated results of individual liver function tests (P < .001). A logistic regression model using age, presence of jaundice at ERCP, levels of alkaline phosphatase and albumin, and ultrasonography showing dilated ducts or visible CBD stones was found to have a specificity of 75% and a sensitivity of 89%. Past pancreatitis or elevated results of individual liver function tests were not predictive factors.

CONCLUSION

The use of such a model rather than individual criteria would improve the selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.