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Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration

  • 2019 SAGES Oral
  • Published:
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Abstract

Background

Laparoscopic cholecystectomy (LC) is the criterion standard for treating patients with symptomatic gallstone disease; however, the optimal technique for extracting common bile duct stones remains unclear. Recent studies have noted improved outcomes with single-stage techniques, such as intraoperative endoscopic retrograde cholangiopancreatography (iERCP) and laparoscopic common bile duct exploration (LCBDE); however only few studies have directly compared those two single-stage techniques.

Objectives

Using the American College of Surgeons National Surgical Quality Improvement Program (ACS NSQIP) database, we retrospectively analyzed the postoperative outcomes of all patients who underwent single-stage LC for choledocholithiasis from 2005 to 2017. Using Current Procedural Terminology (CPT) codes, as well as International Classification of Diseases, Ninth Revision (ICD-9) and 10th Revision (ICD-10) codes, we stratified patients into two cohorts: those who underwent iERCP and LCBDE. Applying univariate techniques, we evaluated baseline characteristics and postoperative outcomes for both cohorts. Our primary outcomes of interest were 30-day morbidity and 30-day mortality; our secondary outcomes included rates of reoperation, readmission, operative time, and hospital length of stay.

Results

Of the 1814 single-stage LC patients during our 13-year study period, 1185 (65.3%) underwent LCBDE; 629 (34.6%) underwent iERCP. Our univariate analysis showed that the two cohorts were homogeneous in terms of baseline characteristics, including demographics, preoperative comorbidities, laboratory values, and American Society of Anesthesiologists (ASA) scores. 30-day postoperative morbidity (including infectious and noninfectious complications) and overall mortality between groups were low and comparable. The mean operative time was slightly longer with LCBDE (125.1 ± 62.0 min) than iERCP (113.5 ± 65.2 min; P < 0.001), however the mean hospital length of stay, readmission rate, and reoperation rate were similar.

Conclusion

We found that both iERCP and LCBDE resulted in low, comparable rates of morbidity and mortality. Centers with readily available endoscopic expertise might favor iERCP for its ease of access and shorter operative time. However, LCBDE remains an appropriate technique for patients with choledocholithiasis, especially when immediate endoscopic intervention is unavailable.

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Acknowledgements

We thank the William Harmon Surgical Education and Research Fund for supporting our research. We also acknowledge and thank Mary Knatterud, PhD, for reviewing and editing this manuscript.

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Authors and Affiliations

  1. Department of Surgery, University of Minnesota, Mayo Mail Code 450, 420 Delaware St SE, Minneapolis, MN, 55455, USA

    Victor Vakayil & James V. Harmon

  2. University of Minnesota Medical School, Minneapolis, MN, USA

    Samuel T. Klinker & Megan L. Sulciner

  3. Department of Surgery, University of Pittsburgh, Pittsburgh, PA, USA

    Reema Mallick

  4. Division of Gastroenterology, Department of Medicine, University of Minnesota, Minneapolis, MN, USA

    Guru Trikudanathan, Stuart K. Amateau & Martin Freeman

  5. Department of Surgery, New York University-Langone, Brooklyn, NY, USA

    Helen T. Davido

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  1. Victor Vakayil
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Victor Vakayil, Samuel T. Klinker, Megan L. Sulciner, Reema Mallick, Guru Trikudanathan, Stuart Amateau, Helen T. Davido, Martin Freeman, James V. Harmon have no conflicts of interest or financial ties to disclose.

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Vakayil, V., Klinker, S.T., Sulciner, M.L. et al. Single-stage management of choledocholithiasis: intraoperative ERCP versus laparoscopic common bile duct exploration. Surg Endosc 34, 4616–4625 (2020). https://doi.org/10.1007/s00464-019-07215-w

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