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Prevalence and Predictors of Unnecessary Endoscopic Retrograde Cholangiopancreatography in the Two-Stage Endoscopic Stone Extraction Followed by Laparoscopic Cholecystectomy

  • Hyun Woo Lee
  • Do Hyun ParkEmail author
  • Jae Hoon Lee
  • Dong Wook Oh
  • Tae Jun Song
  • Sang Soo Lee
  • Dong-Wan Seo
  • Sung Koo Lee
  • Myung-Hwan Kim
  • Ji Eun Moon
Original Article
  • 87 Downloads

Abstract

Backgrounds

A two-stage procedure involving endoscopic retrograde cholangiopancreatography (ERCP), followed by cholecystectomy, is one of the primary treatments of concomitant gallstones and choledocholithiasis. However, negative findings on ERCP and migrating gallstones after cholecystectomy are major concerns. This study aimed to identify the prevalence of unnecessary ERCP and to develop and validate a predictive nomogram using preoperative factors in patients who underwent a two-stage procedure.

Methods

Consecutive 931 patients were treated with the two-stage procedure for evident gallstones and suspected choledocholithiasis. After the cholecystectomy, a cholangiogram was performed to confirm the absence of the migrating gallstones. The patients were divided into derivation (n = 652) and validation (n = 279) cohorts.

Results

A total of 26.5% (247/931) patients had unnecessary ERCP (negative choledocholithiasis, 14.6%; migrating gallstones, 11.9%). No stones on images (P < 0.001), total bilirubin < 1.2 mg/dL (P = 0.006), and common bile duct diameter < 8.0 mm (P = 0.004) were independent factors associated with negative finding on ERCP with a validated nomogram area under the curve (AUC) of 0.72 (95% confidence interval [CI] 0.64–0.80). For migrating gallstones after cholecystectomy, radiolucent gallstones (P < 0.001), gallstone size ≤ 6.4 mm (P = 0.001), cystic duct stones (P < 0.001), gallbladder wall thickness ≥ 3.2 mm (P = 0.003), and low-lying cystic duct (P < 0.001) were independent factors with a validated nomogram AUC of 0.77 (95% CI 0.68–0.87).

Conclusions

About one fourth of the patients may have unnecessary ERCP in the two-stage procedure. Based on our nomogram using preoperative factors, high-risk patients who are more likely to perform unnecessary ERCP could be considered for the one-stage procedure.

Keywords

Endoscopic retrograde cholangiopancreatography Cholecystectomy Gallstones Choledocholithiasis Two-stage procedure 

Notes

Compliance with Ethical Standards

Conflict of Interest

The authors declare that they have no conflicts of interest.

Supplementary material

11605_2018_4090_Fig3_ESM.png (128 kb)
Supplementary Figure 1

The flow protocol of the study. ERCP, endoscopic retrograde cholangiopancreatography; ENBD, endoscopic nasobiliary drainage; CBD, common bile duct (PNG 127 kb)

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High Resolution Image (TIF 1308 kb)
11605_2018_4090_Fig4_ESM.png (1.1 mb)
Supplementary Figure 2

Nomogram to predict (A) negative choledocholithiasis on ERCP and (B) migrating gallstones after two-stage procedure. CBD, common bile duct; GB, gallbladder (PNG 1156 kb)

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High Resolution Image (TIF 2288 kb)
11605_2018_4090_Fig5_ESM.png (1.2 mb)
Supplementary Figure 3

(PNG 1208 kb)

11605_2018_4090_MOESM2_ESM.tif (2 mb)
High Resolution Image (TIF 2073 kb)
11605_2018_4090_MOESM4_ESM.docx (20 kb)
ESM 4 (DOCX 19 kb)

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Copyright information

© The Society for Surgery of the Alimentary Tract 2019

Authors and Affiliations

  • Hyun Woo Lee
    • 1
  • Do Hyun Park
    • 2
    Email author
  • Jae Hoon Lee
    • 3
  • Dong Wook Oh
    • 2
  • Tae Jun Song
    • 2
  • Sang Soo Lee
    • 2
  • Dong-Wan Seo
    • 2
  • Sung Koo Lee
    • 2
  • Myung-Hwan Kim
    • 2
  • Ji Eun Moon
    • 4
  1. 1.Digestive Disease Center and Research Institute, Department of Internal MedicineSoonchunhyang University school of MedicineBucheonSouth Korea
  2. 2.Division of Gastroenterology, Department of Internal MedicineUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulSouth Korea
  3. 3.Division of Hepatobiliary and Pancreatic Surgery, Department of SurgeryUniversity of Ulsan College of Medicine, Asan Medical CenterSeoulSouth Korea
  4. 4.Department of Biostatistics, Clinical Trial CenterSoonchunhyang University Bucheon HospitalBucheonSouth Korea

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