ERCP during lap chole tied to best outcomes for choledocholithiasis

Last Updated: 2018-06-06

By Marilynn Larkin

NEW YORK (Reuters Health) - For patients with gallstones in the common bile duct, a so-called rendezvous approach is associated with the highest rates of safety and success compared with three other techniques, researchers in Italy say.

The rendezvous approach, as described by the authors, involves laparoscopic cholecystectomy (LC) plus intraoperative endoscopic retrograde cholangiopancreatography (ERCP). The Italian team conducted a systematic review and network analysis to compare outcomes with this approach to outcomes with LC plus preoperative or postoperative ERCP, or with common bile duct exploration during LC (LCDBE).

As reported online May 30 in JAMA Surgery, Dr. Claudio Ricci of the University of Bologna and colleagues identified 20 randomized clinical trials comparing at least two of the techniques, including 2,489 patients/procedures. Using surface under the cumulative cumulative rating curve (SUCRA), LC plus intraoperative ERCP had the highest probability of being the most successful (SUCRA, 87.2%) and safest (SUCRA, 69.7%) with regard to morbidity.

Overall mortality was similar among the procedures. LC with LCBDE was best for avoiding overall bleeding (SUCRA, 83.3%), for the shortest operative time (SUCRA, 90.2%) and lowest total cost (SUCRA, 98.9%).

LC with intraoperative ERCP was the best approach for length of hospital stay (SUCRA, 92.7%). LC plus LCBDE was safest with respect to acute pancreatitis (SUCRA, 80.3%), but that approach was worst with respect to biliary leak (SUCRA, 4.9%).

Limitations included selection bias, different types of patients, and differences between centers in the performance of the same procedures, according to the authors.

Summing up, they stated, "In terms of morbidity and success rate, the rendezvous approach seemed to perform best. However, the other 3 procedures had specific advantages and disadvantages: LC plus LCBDE helped avoid acute pancreatitis, but it had a risk for biliary leaks; (preoperative) ERCP plus LC was indisputably the worst choice in terms of acute pancreatitis. Finally, LC plus (postoperative) ERCP was rarely studied, and it was the one with the lowest success rate."

Dr. Matthew Dong, Assistant Professor of Surgery at the Icahn School of Medicine at Mount Sinai in New York City, told Reuters Health by email, "the authors did an admirable job of trying to account for study variance and draw the best conclusions they could from the available information."

"From a practical standpoint, this study examines only . . . a small subset of patients with gallbladder disease (and) its findings are relevant only to that population," he said. "The study demonstrates a significantly decreased hospital stay for patients who have ERCP to clear stones from their duct at the same time as their surgery to remove their gallbladder."

"This is intuitive," he explained, "because if this procedure is done before or after the surgery, it will frequently be performed on a different day, often in a different facility. Complications vary depending on the management strategy employed."

"It is important to emphasize that all of these techniques require a skilled specialist and that these specialists are not always available at all times in all locations," he noted. For example, "laparoscopic common bile duct exploration is a technically challenging surgical procedure with its own set of special equipment that is not universally available."

"The practical options at a given hospital at a given time may be quite variable depending on the facilities, equipment, and (available) personnel," he concluded.

Dr. Rajesh Keswani, Director of Quality in the Digestive Health Center at Northwestern Memorial Hospital in Chicago, told Reuters Health in an email, "I agree that the findings adequately represent the available literature comprised of randomized clinical trials."

However, like Dr. Dong, he said, "it is unclear whether these findings represent what would be seen if we implemented these treatment algorithms in the 'real world' where there are many challenges."

"Specifically, coordinating an intra-operative ERCP with a laparoscopic cholecystectomy is often logistically challenging," he noted. "Outside of a trial, it may not be feasible, as the surgeon may not also perform the ERCP; this may result in longer surgical times, as the surgeon waits for the ERCPist."

"This may be an example where this no single correct algorithm and instead centers need to rely upon their local expertise," Dr. Keswani said. "Ultimately, you are not comparing procedures - you are comparing physicians performing procedures. Each center needs to realistically appraise their skills to determine an optimal treatment algorithm."

"That said, these data certainly suggest that surgical training programs should emphasize training in laparoscopic common bile duct exploration as much as they emphasize cholecystectomy training," he concluded.

Dr. Ricci did not respond to requests for a comment.

SOURCE: http://bit.ly/2M3Mc4P

JAMA Surg 2018.