Catherine McKeever
Introduction
Guidelines for the management of symptomatic gallstone pathology advise for bile duct clearance and cholecystectomy, but give no clear directive of preference between endoscopic retrograde cholangiopancreatography (ERCP) followed by laparoscopic cholecystectomy (LC), as opposed to LC with bile duct exploration (LCBDE). The impact of pre-operative ERCP on operative outcomes and day-case suitability is unclear, despite this being a key service target.
Methods
A retrospective cohort study was performed at a high-volume centre. In this study, patients with pre-operative ERCP were compared to those undergoing emergency cholecystectomy. Outcomes included length of stay (LOS), intra-operative BDE, complications, and conversion to open or partial cholecystectomy.
Results
- 353 patients were included (69 ERCP, 284 emergency cholecystectomy)
- There was no significant difference between BDE (7.25% vs 4.9%) or overall complications (8.7% vs 7.4%)
- However, patients with prior ERCP were significantly more likely to require conversion to open or subtotal cholecystectomy (7.2% vs 1.1%, p<0.05)
- Length of stay was longer in the ERCP group (median 0, IQR 0-3 vs 0-1)
- Rates of same-day discharge were similar between groups (55.07% vs 54.58%)
- Of patients undergoing ERCP, 47.8% had no documented features of acute obstruction
Conclusion
Pre-operative ERCP is associated with increased conversion rates and subtotal cholecystectomies without improving overall complication rate or same-day discharge when compared to emergency cholecystectomy alone. These findings, alongside potential overuse of ERCP in patients without acute obstruction, support consideration of a stronger recommendation for emergency cholecystectomy as the initial management for symptomatic gallstone disease.
Authors
Catherine McKeever, Teri Toi, Bhaskar Gopakumar
Norfolk and Norwich NHS Foundation Trust, Norwich, United Kingdom