Role of endoscopic retrograde cholangiopancreatography for suspected choledocholithiasis in patients undergoing laparoscopic cholecystectomy

Background: We report our experience of selective cholangiography in a series of laparoscopic cholecystectomies and evaluate the strategy of using "stricter criteria" to select preoperative endoscopic retrograde cholangiopancreatography (ERCPs). Methods: A total of 1847 consecutive laparoscopic cholecystectomies were analyzed for use of cholangiography. A high risk of common bile duct stones (bilirubin level more than 2 mg/dL, jaundice, alkaline phosphatase level more than 150 U/L, pancreatitis, or dilated bile duct and/or stone on ultrasound or CT) was an indication for preoperative ERCP. Selective intraoperative cholangiography was performed for intermediate risk of bile duct stones. The strategy of using "stricter criteria" (jaundice and/or demonstrated bile duct stones on ultrasound or CT) for selecting preoperative ERCP was evaluated retrospectively. Results: Preoperative ERCP was performed in 135 patients (7.3%) and demonstrated bile duct stones in 43 (32%). Of 36 patients with mild gallstone pancreatitis alone, stones were found only in 6 patients (17%). Selective intraoperative cholangiography was performed in 87 (5%), and stones were found in 2 (2%); 67 (3.6%) postoperative ERCPs were performed for suspected choledocholithiasis, and stones were found in 21 (32%). Applying "stricter criteria" to select preoperative ERCP would predict ductal stones in 56%, whereas 3% of patients with stones would be missed, resulting in a 50% reduction in preoperative ERCPs. Conclusions: Even in selected patients considered likely to have choledocholithiasis, the diagnostic yield of preoperative ERCP is low. Using "stricter criteria" to select patients for preoperative ERCP can avoid unnecessary ERCPs.