Laparoendoscopic Rendez Vous Versus Standard Two Stage Approach for the Management of Cholelithiasis/Choledocholithiasis
Laparoendoscopic Rendez Vous Versus Standard Two Stage Approach for the Management of Cholelithiasis/Choledocholithiasis
The purpose of the study is to assess whether combined intraoperative ERCP and CBD clearance
 with laparo-endoscopic rendez-vous during laparoscopic cholecystectomy (one stage approach)
 is or not superior to the standard practice of preoperative ERCP, sphincterotomy and CBD
 clearance followed by laparoscopic cholecystectomy (two stage approach) in patients with
 combined cholelithiasis and choledocholithiasis.
The ideal management of concomitant cholelithiasis and choledocholithiasis is not known yet.
 There are several options, including one-stage or two-stage approaches. The most commonly
 used practice is the two-stage management which consists of preoperative ERCP, sphincterotomy
 and CBD clearance followed by laparoscopic cholecystectomy. However, with this approach, a
 number of patients will be submitted to an unnecessary ERCP while some others will develop
 complications, mainly pancreatitis due to inadvertent pancreatic duct cannulation.
 Laparo-endoscopic rendez-vous methods have been described in order to obtain selective CBD
 cannulation and omit the risk of post-ERCP pancreatitis. In this procedure, during
 laparoscopic cholecystectomy, a wire is inserted through the cystic duct into the common bile
 duct, advanced into the duodenum where is found endoscopically, gripped with a snare and
 retrieved through the mouth. The a sphincterotome is inserted over the wire and elective CBD
 cannulation is obtained to be followed by sphincterotomy and CBD clearance intraoperatively.
 The method has been described by several authors in small to moderate case series, its safety
 has been proven and it appears that reduces both the length of hospital stay and the
 incidence of post-ERCP pancreatitis.However, it has not been popularized and has never been
 tested over the standard two-stage management. In our hospital, the standard approach for
 cholelithiasis and choledocholithiasis has been, as well, the two-stage (preop ERCP and
 sphincterotomy followed by laparoscopic cholecystectomy)approach. We initially assessed the
 feasibility and safety of the laparo-endoscopic rendez vous with a pilot study and now we
 intend to compare the two methods in a prospective randomized trial.
Inclusion Criteria:

 -  patients must be able to give informed consent preoperatively

 -  ASA I-III

 -  patients at high risk to have CBD stones (jaundice, cholangitis, grossly deranged
 LFTs, CBD stones found on US or MRCP)

 Exclusion Criteria:

 -  patients not fit for surgery (ASA IV)

 -  previous ERCP and sphincterotomy

 -  previous upper abdominal surgery

 -  pregnancy at time of surgery