Single Setting ERCP and Laparoscopic Cholecystectomy is a Safe Procedure in Patients With Cholecysto-Choledocholithiasis
Single Setting ERCP and Laparoscopic Cholecystectomy is a Safe Procedure in Patients With Cholecysto-Choledocholithiasis
The ideal management of cholecysto-choledocholithiasis is an open cholecystectomy (OC) with
 the common bile duct (CBD) exploration worldwide. The single setting 2-stage approach-
 endoscopic retrograde cholangiopancreatography (ERCP), endoscopic sphincterotomy (EST), and
 CBD clearance followed by laparoscopic cholecystectomy (LC) offers an advantage, mainly by
 reducing the hospital stay, the cost, and the morbidity. Investigators did a prospective
 study in patients admitted for the management of the cholecysto-choledocholithiasis in the
 Department of Surgery at the Lumbini Medical College and Teaching Hospital from November
 2012- October 2015. They underwent 2-stage ERCP+LC in a single setting and investigators
 compared them with 2-stage OC+CBD exploration in a single setting approach. The patients with
 the open procedure were the investigator's control groups. All the included cases in the
 study were elective.
This was a prospective study done on patients admitted for management of the
 cholecysto-choledocholithiasis in the Department of Surgery at the Lumbini Medical College
 and Teaching Hospital from November 2012 - October 2015. This is a peripheral setting
 hospital located in a remote city of Nepal-"Palpa". The study was approved by the
 institutional ethical committee- "IRC of Lumbini Medical College and Teaching Hospital" and
 written consent was obtained from all of the patients. A comprehensive literature search
 published in English was done till 2019 using Hinari, PubMed, Cochrane Library, EMBASE, Web
 of Science, and ScienceDirect.

 This is an interim analysis of 160 patients with 83 (51.9%) patients in ERCP+LC and 77
 (48.1%) in open procedure (OC with CBD exploration) group respectively. The primary objective
 was to compare the single setting ERCP+LC with OC+CBD exploration and the secondary
 objectives were to study 1) the feasibility of the procedure, 2) detect the morbidity
 (cholangitis, pancreatitis, abdominal collection, and wound infection), 3) the length of
 stay, and ). The stone clearance respectively. The investigators defined their single-setting
 procedure as ERCP followed by LC. The patients from an open procedure group were those who
 underwent the procedure before our team was trained to carry out the ERCP. This open
 procedure group also included 10 patients who underwent open surgery due to unsuccessful
 ERCP. And finally, investigators compared ERCP+LC group with those who underwent the open
 procedure. The inclusion and exclusion criteria for ERCP+LC and open procedure are shown in
 Table 1 and Table 2 respectively.

 After being informed about the related therapeutic maneuver, the patients were chosen for the
 sequence of endoscopic procedures and LC. And, the unsuccessful patients underwent through
 the OC with CBD exploration along with choledochoscopy. General anesthesia with nasal
 endotracheal intubation was done in all the patients. Antibiotic prophylaxis was given
 according to the standard recommendation for cholecystectomy.18 The ERCP procedure was
 performed with the patients in the prone position. A duodenoscope (TJF160R, Fujinon, Japan)
 was inserted into the second segment of duodenum via the mouth. A cholangiogram was carried
 out using C-arm X-ray (SIEMENS) and an EST was performed to extract the CBD stones. The
 stones were removed by basket or balloon catheter. Stones larger than 10 mm were removed
 using a mechanical lithotripter. Following ERCP, care was taken to remove all the gas from
 the stomach to facilitate LC. The patients were then placed in the reverse Trendelenburg
 position. LC was performed using the four trocar technique. A sub-hepatic drain was
 positioned if there was any concern about the possible bile leakage or bleeding in the
 postoperative period.

 In cases of failed ERCP, the patients were placed in the supine position and OC with CBD
 explorations were performed in the same setting. A right subcostal incision was given for the
 open surgery. Cholecystectomy was performed ante-grade or retro-grade technique depending
 upon the anatomical variations of the gallbladder. CBD was opened below the opening of the
 cystic duct and stone clearances were done. To assure the stone clearances intraoperative
 choledochoscopies were performed. All the procedure viz. ERCP, LC, and open surgeries were
 performed by an experienced single surgeon and his team.

 The statistical data were analyzed with a t-test, Pearson's χ2, Fisher's exact test, Mann
 Whitney's test, and Kruskal Wallis test using a statistical analysis program (SPSS 16), p
 <0.05 was considered statistically significant.
Inclusion Criteria:

 1. All the sonological proven cases of choledocholithiasis with cholelithiasis.

 2. CBD diameter <2cm.

 3. Age >13 yrs.

 Exclusion Criteria:

 1. Clinical, radiologic, or biochemical evidence of cholangitis and pancreatitis.

 2. Evidence of cirrhosis, intrahepatic gallbladder, liver mass or abscess, neoplasm,
 Suppurative or necrotizing cholecystitis, gall bladder empyema, or perforation,
 Pregnancy.

 Age >85 yrs.