Complication Rates Associated With Access or Not to Endoscopic Retrograde Cholangiopancreatography (ERCP) in Units Performing Cholecystectomy, When Common Bile Duct Stones Are Detected on Intraoperative Cholangiography

Annually, approximately 15,000 cholecystectomies are performed in Sweden. Cholecystectomy is indicated if gallstones cause recurrent biliary colic or complications. Gallstones can pass from the gallbladder into the common bile duct. Common bile duct stones (CBDS) can potentially cause biliary obstruction, cholangitis and pancreatitis.

Intraoperative cholangiography (IOC) during cholecystectomy is performed as a standard in Swedish surgical units. The arguments for routine IOC are several; routine IOC is associated with reduced risk of bile duct injury in patients with previous or ongoing cholecystitis, early detection of bile duct injury has been suggested to improve survival, and CBDS found by IOC, even small ones <4 mm, are associated with increased risk of complications and need for unplanned endoscopic retrograde cholangiopancreatography (ERCP) if no effort is made to clear the common bile duct.

American guidelines suggest performing IOC as a routine in adult patients undergoing laparoscopic cholecystectomy. Many countries do not practice routine IOC because it prolongs cholecystectomy and the evidence supporting its use is considered insufficient. European guidelines do not include routine IOC as a recommendation. On the other hand, both American and European guidelines advocate treatment of all CBDS, symptomatic or not.

CBDS represent a well-recognized clinical dilemma, especially when encountered first on IOC during cholecystectomy. In those situations, intraoperative treatment of CBDS has not been planned in advance.

There are several different approaches to remove CBDS. Worldwide, the two most common methods used are preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy, or laparoscopic exploration of the common bile duct during cholecystectomy. In Sweden, the predominant treatment strategy for CBDS encountered on IOC is intraoperative ERCP.