Selective endoscopic cholangiography for the detection of common bile duct stones in patients with cholelithiasis

Background and Study Aims: The detection and management of common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy continues to be controversial. Several diagnostic and therapeutic strategies have been suggested. These include intraoperative cholangiography, selective endoscopic retrograde cholangiopancreatography (ERCP), magnetic resonance cholangiopancreatography, and endoscopic ultrasonography. The aim of this study was to evaluate the efficacy of selective ERCP in detecting CBD stones in patients with cholelithiasis before laparoscopic cholecystectomy. Patients and Methods: In a prospective study, patients with cholelithiasis who presented during a 6-year period were assessed on a selective basis with ERCP for suspected CBD stones before laparoscopic cholecystectomy. ERCP was carried out if the patient had any of the following criteria: a dilated CBD on ultrasound, gallstone pancreatitis, or abnormal liver function tests. Intraoperative cholangiography was not performed in any of the patients. Long-term follow-up was undertaken. Results: The study included 427 patients. On the basis of selective criteria, ERCP was carried out in 41 patients (9.6 %), with confirmed CBD stones in 22 cases (53.7 %). The most useful predictor of CBD stones on ERCP was the presence of a dilated CBD in association with abnormal liver function tests. In this situation, CBD stones were identified in 14 of 17 cases (82%). Abnormal liver function tests alone had a sensitivity of 50% (four of eight). All other parameters used in isolation had a lower detection rate. During a median follow-up period of 6 years (range 1-10 years), six of 386 patients (1.6%) with initially normal imaging and biochemical tests presented again with retained stones. All were successfully managed by ERCP and sphincterotomy. There were no major complications. Conclusions: Preoperative selective ERCP is effective in detecting clinically significant CBD stones. However, there is a high false-negative rate when a single criterion is used to guide therapy. Multivariate analysis of preoperative parameters for risk stratification, in conjunction with other imaging modalities, may make it possible to minimize unnecessary ERCPs.