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Suspected Bile Duct Stones Before Laparoscopic Cholecystectomy:Impact of Patient Selection on ERCP Utilization
Glenn Gross, Laura Rosenkranz, Juliane Bingener, University of Texas Health Science Center at San Antonio, San Antonio, TX; Melanie Richards, University of Texas Health Science at San Antonio, San Antonio, TX; Wayne Schwesinger, Kenneth Sirinek, University of Texas Health Science Center at San Antonio, San Antonio, TX

The management of suspected bile duct stones (BDS) in patients undergoing laparoscopic cholecystectomy (LC) remains controversial and depends on local technical expertise. This 12-year study evaluates the effect of more stringent selection criteria for pre-operative ERCP implemented over the last 6 years of the study period.

METHODS: All patients undergoing LC from 1992-2003 were evaluated for the utilization and findings of ERCP. The indications for pre-LC ERCP from 1992-1997 were one or more of the following: hyperbilirubinemia, bile duct dilation, and elevated liver-associated enzymes. The criteria for pre-LC ERCP from 1998-2003 were that the patient must have at least two of the following:hyperbilirubinemia, ductal dilation, and persistently abnormal or rising liver-associated enzymes. RESULTS:Of 7583 patients who underwent LC 1,319 patients (17%) had pre-LC ERCP and 347 (5%) had post-LC ERCP. BDS were extracted from 763 patients (10%), in 626 (82%) at pre-LC ERCP and in 137 (18%) at post-LC ERCP. ERCP findings are summarized below:

Table 1

	1st Period	2nd Period	Overall Series
Pre-LC ERCP	1992-1997	1998-2003	1992-2003
# patients	807/2810 (29%)	512/4773 (11%)	1319/7583 (17%)
BDS found	348/807 (43%)	278/512 (54%)	626/1319 (47%)

Table 2

	1st Period	2nd Period
Post-LC ERCP	1992-1997	1998-2003
# patients	141/2810 (5% of LC)	206/4773 (4% of LC)
# BDS	48/141 (34%)	89/206 (43%)
# leak/stricture	34/141 (24%)	28/206 (14%)
# normal	59/141 (42%)	89/206 (43%)

CONCLUSIONS: Application of more stringent selection criteria for pre-LC ERCP decreased use of pre-LC ERCP (29% vs. 11%) and improved BDS detection at pre-op ERCP (43% vs. 54%) without increasing use of post-LC ERCP (5% vs. 4%). Use of these criteria prevented unnecessary ERCP for 872 patients during the second six year period. Careful patient selection can diminish unnecessary procedures in patients suspected of having BDS at the time of LC and avoid potential complications of ERCP.

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