Laparoscopic cholecystectomy for GSD is the most common surgery performed worldwide, and about 10–18% of patients undergoing LC have CBD stones as well (1). The appropriate management for these patients involves clearance of the CBD stones, in addition to removal of the gallbladder to prevent recurrent biliary events. The apt method of dealing with CBD stones largely rests on the availability of local resources, technical skill of the surgeon and the endoscopist. These may range from open CBD exploration to the modern minimally invasive Laparoscopic CBD Exploration (LCBDE), in addition to the widely used ERCP. While LCDBE may offer a single stage therapy, it requires considerable surgical skill in laparoscopic suturing and additional resources (8–9). ERCP on the other hand, is widely practiced, and is the most common method of dealing with choledocholithiasis worldwide (10). Studies have shown early LC following ERCP to be beneficial, when the surgery is done prior to the inflammation setting in the hepatoduodenal region, but no guidelines as to when the surgery should be performed have been established (11–12). Same day ERCP and LC, can offer the benefits of a single stage procedure, reduce hospital stay and costs, in patients whose CBD stones can be dealt with endoscopically, and where facilities or resources needed to perform LCBDE are unavailable (13–16).
While some authors have advocated intraoperative ERCP and LC done under the same general anesthesia as an option, it is worthwhile to note that this method has several logistical drawbacks. It might not always be feasible to have the endoscopy team in the operation theatre, and performing ERCP on a supine patient can be technically challenging even for the experienced endoscopist (17–18).
In order to overcome these challenges, we adopted an alternative same-day sequential approach - ERCP preoperatively in the endoscopy suite under Propofol sedation, followed by LC in the operation theatre under general anaesthesia. This method offered several advantages - the ERCP could be performed in a comfortable semi-prone position, making cannulation easier, as we reported successful CBD cannulation in all our patients. There were no instances of post-ERCP pancreatitis, although self-resolving asymptomatic hyperamylasemia was seen in 5 patients and was related to inadvertent pancreatic duct cannulation and multiple attempts at guidewire insertion, as has been noted in other studies as well (12, 13, 15). The decision to exclude patients with large CBD stones (> 2cm) from our study, could contribute to the fact that ERCP was successful in achieving complete CBD clearance in all the patients. The mean total procedure time for ERCP was 33.3 minutes which was comparable to that of other studies found in literature (12, 13, 16).
Our study involved immediate shifting of patients from the endoscopy suite to the operating theatre, and the average time interval between the two procedures was only 51 minutes, which was much less compared to other similar studies. (13, 15, 16)
Successful ERCP guided CBD clearance and absence of any immediate post procedure complications enabled us to proceed with LC safely. There was no need for intraoperative cholangiography, as CBD clearance had been documented. Bowel distension has been reported in literature to be a problem during LC after ERCP, however the use of CO2 for insufflation during ERCP helped us to prevent any bowel distension in our study (12, 14, 15). Laparoscopic cholecystectomy was completed safely without the need for conversions in all the patients, which was seen to reflect results in other studies (12–16). The mean operating time was 80.4 minutes, and comparable to the literature reviewed (12–16). Only 1 patient had a complication of post-op biliary leak which was self limiting and managed conservatively. The average post procedure LOS was 3.7 days, and was similar to other studies that had performed single-stage procedures (12, 15). This translates into decreased hospital stay and reduced healthcare expenses as has been noted by Borreca et al (15). Absence of any mortality and any long-term complications further assured us of the feasibility and safety of this novel approach.
There are several limitations to our study which must be kept in mind. Firstly, the study population was small; secondly, it was a single center study and thirdly there was no control group. Larger multi-institutional randomized controlled trials are needed prior to adopting this method as a standard of care. We also feel that further studies need to be done comparing this method to LCDE or with LC and intraoperative ERCP, before this is widely adopted.