Hi everybody,
Do you prefer 2-stage (Pre/Post-operative ERCP + Lap Cholecystectomy) or single stage (Lap Cholecystectomy + Lap Common Bile Duct Exploration) to treat concomitant gallbladder stones and bile duct stones?
It will depend on a number of factors including age of patient, availbility of ERCP, diameter of CBD and symtom status. I tend to prefer ERCP followed by lap chole as in our instiution we have ready access to ERCP with 7 lists per week, so the majority are dealt with this way. Patients with "difficult" stones and weekend admissions are dealt with by lap chole and CBD exploration.
Simultaneous lap chole + lap CBD exploration has the advantage of doing both procedures at the same time. However it requires considerable laparoscopic expertise and dexterity.
In our institution, we favour pre-op ERCP and lap chole, with excellent results.
It also depends on your institute. In my experience ercp prior to surgery has more favorable outcomes.
i agree with G Garcea, it depends on numerous consideration but usually I favour ERCP then Lap chol
http://ac.els-cdn.com/S0016510709025504/1-s2.0-S0016510709025504-main.pdf?_tid=587024ac-ffdf-11e4-a732-00000aacb360&acdnat=1432229725_5fe8a85302fbff866e29da11386ad63d
click the attachment above this is the current ASGE guidlines, ERCP are reserved for high risk patients prior to Lap choly, there is a nice chart in the lower portion of the article.
Thank you all. As Rahman says, the current ASGE guidelines showed that ERCP prior to lap chole should be confined to high risk patients. In 1999 A Cuschieri et al published the results of a big european multicenter randomized controlled trial (http://www.ncbi.nlm.nih.gov/pubmed/10526025), showing the advantages of the single stage approach over the two stage approach in terms of shorter hospital stay, with equivalent success rates and patients morbidity. Anyway, to date, the vast majority of cases is approach with ERCP and Lap Chole. What is, in your personal opinion, the main reason because of the two stage approach is still so followed?
Hello. Ideally solve everything in one act with surgical exploration of the bile duct laparoscopically, either via transcystic instrumentation or in any case, the cisticotomia and primary closure. this also depends on the characteristics of the patient, in which you find yourself centers and skills of the surgeon.
I opt for ERCP first instance in patient risk or cholangitis.
The published trials and other studies/consensus reports pretty much say that ercp+lap is equivalent to single stage approaches for CDB stones distal to the cystic duct (and for stones impacted in the gb neck or cystic duct), for successful clearance and complications, but a single stage approach favors shorter length of stay and lower total costs. BD Stone disease proximal to the cystic duct is a different matter and not really addressed in these studies.
Other studies show lap/robot chole +IOC, followed by ERCP for hard documentation of CBD stones also lowers cost and length of stay over ERCP first in patients meeting moderate or low risk criteria.
I don't know of any studies off hand for putting EUS into the protocol for acute presentation, but among those of us who do both EUS and ERCP, EUS is far more specific and sensitive in detecting choledocholithiasis and inflammatory changes to the ducts and gb than any other imaging modality (other than intraoperative ultrasound). IOC does suffer from false positives and negatives.
I personally favor EUS screening any time there is lack of hard evidence of stones prior to ERCP, but being done together as a potential single session . If nothing else, EUS is much lower risk and lower cost (at least is the US currently) than ERCP. However, I am not aware of any studies showing a reduction in total costs or length of stay using EUS/ERCP in the acute setting. In the chronic setting, ERCP (without cholangioscopy) routinely misses stones 5 mm and smaller, and fails to clear the CHD/CBD in 10-20% of cases. Cholangioscopy and/or EUS fix these misses with high sensitivty/specificity.
For patients presenting with ascending cholangitis and usual anatomy, ASGE and multiple studies all favor ERC first, presumably because patients can deteriorate very quickly and ERC is likely to get done and clear the duct more quickly than PTC or LCBDE, as well as not have to deal with a crashing pt in the OR setting.
Like all of the options of which technique to offer first, second, third, etc, there is underlying bias based on the specialist-focus doing the studies, as well as the specific availability of specialists/equipment/staff/facilities, the economic and colleagial opportunities and constraints, patient preferences, and other unspoken realities of health care delivery. These elements always drive local functional practice.
Generally ERCP, Cbd stone extraction followed by lap cholecystectomy.
The upcoming sunflower study may inform the literature further on the sequelae of CBD stones and use of MRCP prior to surgery
It may be more correlated with biliary status .take into account pt morbidity and presentation of illness ... 2 stage approach more safety and single stage is more favorable in stable and complicated biliary stones