Timing of ERCP and laparoscopic cholecystectomy in the treatment of choledocholithiasis

Although experience with laparoscopic approaches to common duct stones is increasing, ERCP performed either pre or post laparoscopic cholecystectomy (LC) remains the most common approach. Debate remains as to the best timing for ERCP in patients with suspected choledocholithiasis. Because clinical, laboratory and radiological data are poor predictors of choledocholithiasis, many ERCPs done before LC are negative studies. ERCP performed after LC with a positive intraoperative cholangiogram (IOC) would eliminate many unnecessary preop endoscopic studies. This is a retrospective analysis of the treatment of choledocholithiasis with the combination of LC and ERCP. Two groups of patients were compared, those who underwent ERCP followed by LC with those who underwent LC and IOC followed by ERCP. No significant difference was found with respect to preop patient characteristics, clinical presentation, and operative characteristics. A significant difference was found in hospital stay and cost, both favoring the postop ERCP group. The postop ERCP group also had fewer complications. In the absence of cholangitis requiring emergent ERCP, patients with suspected choledocholithiasis could be successfully managed first with LC, reserving ERCP for a positive IOC, This eliminates many negative preop ERCPs.