To the Editor:
There is still no consensus regarding the management of patients with choledocholithiasis who are to undergo laparoscopic cholecystectomy (LC) for cholelithiasis. This is a practical and common problem for clinicians. Therefore, articles such as that by Iodice et al.
1
that recently appeared in Gastrointestinal Endoscopy are of interest. These investigators reported a large series of patients who were managed by single-step endoscopic-laparoscopic treatment. This report is welcomed, but there are a few points that require further discussion.As Iodice et al.
1
stated, there are a variety of therapeutic options available for patients with stones in the bile duct as well as the gallbladder. However, because LC has rapidly become the treatment of choice for cholelithiasis, there is an increasing focus on the treatment of associated choledocholithiasis by LC. But because of the great skill and experience required for the management of both problems by LC alone, there is also a growing interest in the concept of ERCP-LC as a single-stage treatment.2
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Iodice et al.
1
performed LC in 812 patients over a 3.5-year period regardless of whether stones were unsuspected, suspected, or known. Intraoperative cholangiography was obtained in all patients at LC. If stones were demonstrated, ERCP was performed during the LC procedure. The mean time required for the combined procedure was nearly twice that of LC alone. A mean of 22 minutes was required for alerting the endoscopic team and for the installation of the ERCP equipment and team in the surgical theater. Although the time required is relatively short, the majority of hospitals are unlikely to be able to match this time.When choledocholithiasis is unsuspected before LC, it is very difficult to quickly organize an unscheduled ERCP during LC. Moreover, it is extremely expensive if an ERCP team has to be on stand-by for every LC. The number of hospitals and surgeons performing LC will certainly increase in number in the future, more so than the number of skilled biliopancreatic endoscopists. There are many hospitals in which more than one surgeon and surgical team perform LC, whereas such hospitals have only a single, or perhaps no, expert biliopancreatic endoscopist. Furthermore, improvements in the pre-LC diagnosis of choledocholithiasis can be expected, mostly because of the diffusion of MRCP. This should reduce the number of cases in which LC is performed in patients with bile duct stones that were unrecognized before the procedure. In this era of managed care and high costs associated with the hospitalization of a patient, it is essential that patients with bile duct stones be managed by the most economical strategy.
When the diagnosis of cholecysto-choledocholithiasis is known before ERCP, it is perhaps better to perform ERCP during the LC session. This is a feasible option, but one that requires coordination of schedules for the surgical and endoscopic teams. Thus, there are a number of potential advantages if both problems can be managed during a single therapeutic session instead of two.
Iodice et al.
1
indicate that they changed their selection criteria for the combined procedure over the course of time, but unfortunately information regarding the reasons for these changes is not presented in their report.The combined LC-ERCP procedure should be compared with ERCP after LC, possibly after the insertion of a biliary endoprosthesis through the papilla during LC, with respect to feasibility, outcome and costs.
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I agree with Iodice et al.1
that when choledocholithiasis is recognized before LC, it can be better managed by the combined endoscopic-laparoscopic approach, at least until surgical expertise for bile duct exploration is widely available. One exception would be the difficult case in which the endoscopic approach would require significantly more time and equipment. This type of procedure is best performed in the endoscopy room with the patient under conscious sedation.References
- Single-step treatment of gallbladder and bile duct stones: a combined endoscopic-laparoscopic technique.Gastrointest Endosc. 2001; 53: 336-338
- Cholecysto-choledocho-lithiasis: The difficult relationship between FRCP and laparoscopic cholecystectomy (letter).Endoscopy. 2001; 33: 727-728
- Intraoperative endoscopic sphincterotomy is a reasonable option for complete single-stage minimally invasive biliary treatment: short-term experience with 57 patients.Endoscopy. 2000; 32: 956-961
- Laparoscopic cholecystectomy (LC), intraoperative endoscopic sphincterotomy (ES) and common bile duct stones (CBDS) extraction for management of patients with cholecysto-choledocholithiasis.Surg Endosc. 1996; 10: 649-652
- Laparoscopic cholecystectomy and intraoperative endoscopic sphincterotomy in the treatment of cholecysto-choledocholithiasis.Gastrointest Endosc. 1999; 50: 532-535
- Intraoperative endoscopic sphincterotomy for common bile duct stones during laparoscopic cholecystectomy.Gastrointest Endosc. 1993; 39: 54-58
- Unsuspected choledocholithiasis first diagnosed at laparoscopic cholecystectomy: treatment by trans-cystic duct stenting and elective stent-guided sphincterotomy.Gastrointest Endosc. 1998; 48: 71-74
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© 2001 American Society for Gastrointestinal Endoscopy. Published by Elsevier Inc. All rights reserved.
