since we have a large medical Gastroenterology dept,our policy is to get the CBD cleared first and then do lap chole.with regard to the timing our paper is almost ready for publication.

Do you verify the results with the post-procedure ERCP or MRCP

Yes ,as it is our practice to stent the duct,contrast is injected at the time of removal of the stent to verify after 2to 3 weeks later.

In my opinion the best time of ercp is the pre surgery time, i mean befor

Lap. Choli, because it will cover both rare possibilieties

1. Failure of cannulation

2. Post sphincterotomy bleeding or perforation

In case of both the situation surgical intervention may be required so that

Cholecystectomy can be done simultaneously

Since one-stage laparoscopic cholecystectomy and common bile duct exploration was adopted as an alternative and preferred treatment for choledocholithiasis in our facility three years ago, two-stage ERCP then laparoscopic cholecystectomy is reserved to patients who refuse immediate surgical intervention and who don't have concomitant acute cholecystitis. From the view point of a surgeon, elective ERCP should be followed by laparoscopic cholecystectomy as soon as possible. In my experience, recurrent obstructive bile duct stone may happen during the interval of a two-stage strategy. However, from the view point of a hospital manager, the following laparoscopic cholecystectomy should be delayed till another hospitalization. The payment system of national health insurance in Taiwan isn't favor of combined ERCP and laparoscopic cholecystectomy in the same hospital course.

Pre-surgical clearance of the stones is preferable either via sphincterotomy or balloon dilation of the papilla, to prevent post op complications.  In patients too ill or with contraindications for sphincterotomy  (on anti-coagulation) you may stent temporarily, and remove stent and stones post op. If surgery is done first there must be a reliable endoscopist on standby to perform the post op ERCP. 

Today in the era of laparoscopy the best approach for CBD stones is controversial. During early part of laparoscopic days CBD exploration and stone removal was considered to be a very complex and cumbersome procedure with significant morbidity. So most patients were managed with pre lap chole ES and stone extraction. But emerging evidence are putting up an argument in favor of one time lap chole and CBD exploration which is more cost-effective and with equal outcome if not better. The severe morbidity of ERCP and ES may be equal to Lap CBD exploration. Indication for preoperative ES are previous complex upper abdominal surgery involving the porta , portal cavernoma, acute cholecystitis and cholangitis. If ES and CBD is cleared it is desirable to do the Lap chole as early as possible. In case of retained CBD stone after Lap CBD, ERCP and ES become imperative.

At present in a fit patient , laparscopic cholecystectomy and lap CBD exploration should be the treatment of choice if otherwise contraindicated.

Pre-cholecystectomy

Pre-cholecystectomy a) to decrease the risk of cholangitis during the waiting time of lap cho, b) if any complication occurs (0.02.0.04% duodenal perforation and bleeding) should be better to manage both procedures (complication and chocec)  in the same time. Another type of question ca be: how should be managed patients wiyh previous CBD but without current evidence of common bile duct stones?

If you are sure on the presence of stones in CBD, ES is mandatory before lap cholecystectomy. If you have some doubt: EUS before.

Preferably to perform endoscopic sphincterotomy with the lithextraction before the cholecystectomy only without the signes of acute pancreatitis