Intraoperative ERCP in a Community Setting, Another Viable Option for Choledocholithiasis, a Review of 396 Cases

Abstract

Purpose: The recommendations for treating choledocholithiasis have focused on pre- or postoperative ERCP, but there have been studies showing shorter hospital stays, reduced costs, and lower morbidity by performing intraoperative ERCP. We reviewed our experience with intraoperative ERCP in a community setting over a 10 year period. Methods: We retrospectively reviewed ERCPs done in our community hospitals from 1999-2009. We reviewed all the inpatient charts indicating an ERCP was performed and located the charts indicating choledocholithiasis. The charts were reviewed and divided into intraoperative(IO), preoperative(PREOP) and postoperative(POSTOP) groups. The IO ERCPs were further broken down into those completed using the rendezvous technique (IO-R) and those in which a wire could not be passed or non rendezvous (IO-NR). Results: We were able to identify 695 Perioperative ERCPs: 396 IO (332 IO-R, 64 IO-NR), 166 PREOP, 133 POSTOP). Average age and gender were similar in the 3 groups (IO, PREOP, POSTOP) (Age = 50.5, 48.8, 46.8; % female = 70.0%, 69.7%, 71.5%). Primary stone clearance rates were IO-90.9% IO-R 92.4%, IO-NR 82.7%, PREOP 87.8%, POSTOP 90.2%. Open duct removal of the stones occurred in 1.3%-IO-R and 5.2% IO-NR. With a second ERCP the ERCP clearance rates were IO-R 98.7%, IO-NR 94.8%, PREOP 100%, POSTOP 100%. Complication rates for post-procedure pancreatitis in the groups: IO 0.25%, PREOP 0%, POSTOP 0.98%, PREOP+POSTOP 0.37% and post op bleeding: IO 0.5%, PREOP 1.2%, POSTOP 0%, PREOP+POSTOP 0.75%. Average total Cholecystectomy+ERCP procedure and anesthetic times in minutes were: IO-R 113.0, 146.6; IO-NR 129.3, 169.0; PREOP 100.5, 135.7; POSTOP 112.3, 152.6. average hospital length of stay (LOS) was calculated in days and was: IO-4.08, PREOP-4.74, POSTOP-3.46, PREOP+POSTOP 4.25. If broken down into those with and without pancreatitis at admission. LOS presenting with pancreatitis: IO 5.44, PREOP 6.13, POSTOP 6.40; LOS without pancreatitis IO 3.73, PREOP 3.94, POSTOP 3.14. If we removed those patients with severe comorbidities at admission (acute MI, CHF, pneumonia) then the average LOS was: IO 3.20, PREOP 3.84, POSTOP 3.27. Conclusion: We found that intraoperative ERCP when compared to PREOP and POSTOP ERCP was as effective in removing stones, had a slightly lower morbidity rate, and a shorter length of stay. Intraoperative ERCP should be included in the options for treating choledocholitiasis.