Endoscopic retrograde cholangiopancreatography in the management of choledocholithiasis with laparoscopic cholecystectomy.

With the advent of laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) has an increasing role in perioperative management. To assess this role, the authors studied, retrospectively, 12 patients who underwent ERCP out of a series of 475 who had laparoscopic cholecystectomy. ERCP was indicated preoperatively for biliary colic in four patients, gallstone pancreatitis in two and common bile duct stone on ultrasonography in one. ERCP was performed postoperatively for jaundice in three patients, for cholangitis in one and for a positive intraoperative laparoscopic cholangiogram in one. Choledocholithiasis was diagnosed in six patients preoperatively and in three postoperatively. Only one patient had an unsuspected residual bile duct stone postoperatively. Of nine patients with stones, endoscopic sphincterotomy was performed in eight and stones were cleared in all with no complications; a stone passed spontaneously in the other patient. ERCP is indicated before laparoscopic cholecystectomy in cases of jaundice, gallstone pancreatitis, cholangitis, abnormal liver biochemistry suggesting cholestasis and ultrasonographic demonstration of either a common bile duct stone or a common bile duct greater than 8 mm in diameter. Operative laparoscopic cholangiography is indicated when the anatomy is unclear or the bile duct appears dilated. If choledocholithiasis is founded, the options include open or laparoscopic common bile duct exploration and intra- or postoperative endoscopic sphincterotomy.