Preoperative Versus Postoperative Endoscopic Retrograde Cholangiopancreatography in Mild to Moderate Gallstone Pancreatitis

Abstract

In patients with mild to moderate gallstone pancreatitis without cholangitis, selective postoperative ERCP and CBD stone extraction is associated with a shorter hospital stay, less cost, no increase in combined treatment failure rate, and significant reduction in ERCP use compared with routine preoperative ERCP.

Practice Guidelines in Acute Pancreatitis

“…For example, in a randomized trial in patients with mild gallstone pancreatitis with high suspicion of persisting common bile duct stones (elevated serum bilirubin, dilated common bile duct, or persistent hyperamylasemia) but without cholangitis, selective postoperative ERCP and CBD stone extraction was necessary in only approximately one in four such patients, and was associated with a shorter hospital stay, less cost, no increase in combined treatment failure rate, and significant reduction in ERCP use compared with routine preoperative ERCP (251). Thus, patients with resolving mild acute pancreatitis can undergo laparoscopic cholecystectomy with intraoperative cholangiography, and any remaining bile duct stones can be dealt with by postoperative or intraoperative ERCP, or by laparoscopic or open common bile duct exploration, depending on local expertise and access to referral centers in cases of unsuccessful ERCP.…”

“…During the course of biliary pancreatitis, progressive increases in serum bilirubin and other liver function tests and persistent dilatation of the common bile duct are strongly suggestive of common bile duct obstruction by gallstones (251)(252)(253)(254). In this circumstance, it is reasonable to proceed directly to ERCP.…”

Meta-analysis of endoscopy and surgery versus surgery alone for common bile duct stones with the gallbladder in situ

“…Complex algorithms were developed 11,12 aimed at predicting the presence of occult choledocholithiasis to select those most likely to benefit from preoperative ERCP, yet a significant false-positive rate remained 13 . A combined approach of laparoscopic intraoperative cholangiography with selective postoperative ERCP to avoid unnecessary procedures has since been proposed 14 . However, ERCP is associated with significant morbidity and mortality 15 .…”

Triple non-invasive diagnostic test for exclusion of common bile ducts stones before laparoscopic cholecystectomy

“…Due to fewer intraoperative cholangiographies during laparoscopic cholecystectomies [6,7] , ERCP has been recommended for pre-or postoperative extraction of CBDS. It is however, an invasive investigation with high risk for complications and should be reserved for selected cases [12,14,15] . MRCP is not available in all institutions and its accuracy depends on the size and position of CBDS [4,11,12] .…”

“…Magnetic-resonancecholangio-pancreatography (MRCP) has high specificity and sensitivity and accuracy similar to that of EndoscopicRetrograde-Cholangio-Pancreatography (ERCP), but its accuracy decreases if gallstones are small (< 4 mm) or if they are located near Vater's papilla [2,5,8,11] . In addition, MRCP is not widely available and unlike ERCP does not allow endoscopic extraction of stones [5,8,12] . ERCP is the most common technique used for both diagnostic and treatment of CBDS.…”