Management and long-term follow-up of patients with positive cholangiograms during laparoscopic cholecystectomy

Abstract

With a goal of minimal invasion during laparoscopic cholecystectomy, the surgeon confronts a judgement decision if the intraoperative cholangiography (IOC) is positive for common bile duct (CBD) stones. The options are postoperative endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic papillotomy (EP), transcystic laparoscopic techniques (LAP), open CBD exploration, or clinical observation. To gather this information, we reviewed the clinical course and IOC of 55 patients with positive IOC during laparoscopic cholecystectomy. Long-term follow-up (1.8 years) was obtained in 50 patients. After review, 48 patients were felt to have CBD stones, and a LAP without choledochoscopy was the initial management in 32 (67%) patients. The remaining patients underwent EP (n = 10), CBD exploration (n = 1), or observation (n = 5). By discharge, 19 (59%) of the 32 LAP patients were successful and had avoided EP while the success rate at follow-up was 48% (14/29). There were no complications after LAP, but we observed a 9.5% (2/21) post-EP pancreatitis rate that required readmission. The success rate for CBD stone clearance with LAP was associated with single stones (87%) and surgeon experience (100% in the last year). The average hospital stay was 1.7 days for LAP and 3.3 days for EP. LAP is safe and eliminates the need for EP in the majority of cases. Although EP is more often successful, it results in a longer hospital stay with an increased risk of complication. We recommend LAP as the initial procedure of choice for a positive IOC.