Comparison of routine and selective endoscopic retrograde cholangiography before laparoscopic cholecystectomy.
To evaluate the role of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy, we compared the frequency of concomitant common bile duct stones, their clinical outcome, and the frequency of bile duct injury between a group of 128 patients with routine preoperative ERC (group A) and 1010 patients with selective ERC (group B). Overall, 48 patients (4.2%) had duct stones, but the predictive signs were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 37 patients in group B, 22 were diagnosed by selective ERC and underwent endoscopic removal. Of four patients whose stones were found by operative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphincterotomy, which failed in one. The stones were not recognized until pain recurred in the remaining 11 patients. Sphincterotomy was successful in nine patients but failed in the other two. Thus postoperative sphincterotomy failed in 3 of 13 patients (23%), necessitating open surgery. Forty-two patients overall (3.7%) had aberrant biliary tract anatomy, which did not lead to bile duct injury in any of the patients. Morbidity of routine ERC (3.1%) was lower than that of selective ERC (7.4%) (p < 0.05). It should be noted that a certain proportion of duct stones may be missed by selective ERC, necessitating laparotomy when sphincterotomy fails. The routine use of preoperative ERC may be justified at institutions where the expertise is available, at least until laparoscopic lithotomy becomes easy.