The effect of time The effect of time interval between interval between

Endoscopic Retrograde Endoscopic Retrograde CholangiopancreaticograCholangiopancreaticogra

phy and Laparoscopic phy and Laparoscopic CholecystectomyCholecystectomy

BYBY

Prof/ GOUDA ELABBANProf/ GOUDA ELABBANSuez canal universitySuez canal university

IntroductionIntroduction

Ten to fifteen percent of all Ten to fifteen percent of all patients with gallstones have patients with gallstones have coexisting common bile duct coexisting common bile duct (CBD) stones in Japan and (CBD) stones in Japan and

Western countries. Western countries.

Introduction Introduction (cont.,)(cont.,)

Endoscopic Sphincterotomy (ES) has Endoscopic Sphincterotomy (ES) has been widely accepted as the standard been widely accepted as the standard procedure for the treatment of (CBD) procedure for the treatment of (CBD) stones. stones.

Although, surgery after successful ES Although, surgery after successful ES for CBD stones remains controversial, for CBD stones remains controversial, many authors advocate it because many authors advocate it because nearly 55% of patients with CBDS have nearly 55% of patients with CBDS have symptoms and half of them have symptoms and half of them have complicationscomplications. .

IntroductionIntroduction (cont.,)(cont.,)

The ideal management of The ideal management of CBD stones is preoperative CBD stones is preoperative endoscopic retrograde endoscopic retrograde cholangiopancreaticography cholangiopancreaticography (ERCP), followed by LC with (ERCP), followed by LC with intraoperative intraoperative cholangiography or cholangiography or intraoperative ERCP to assure intraoperative ERCP to assure the complete clearance of the complete clearance of CBDCBD

Introduction (cont.,)Introduction (cont.,)

The time interval between ERCP and LC The time interval between ERCP and LC is a matter of debate. Some retrospective is a matter of debate. Some retrospective and other prospective studies have and other prospective studies have investigated this issue without sharp clue investigated this issue without sharp clue or definite conclusion. The interval or definite conclusion. The interval usually varies from days to months.usually varies from days to months.

The influence of timing is thought to be The influence of timing is thought to be due to possible inflammation during due to possible inflammation during ERCP that caused by ERCP that caused by bile duct bile duct cannulation, contrast agent infusion and cannulation, contrast agent infusion and sphincterotomy.sphincterotomy.

It is suggested that bile is infected

with bacteria after disruption of Oddi’s sphincter by sphincterotomy and stone extraction during ERCP. Also the procedure leads to an inflammation around the gallbladder, including the hepatoduodenal ligament, making cholecystectomy more risky. This inflammatory response reaches its peak 2 to 6 weeks after ERCP .

Accordingly, the risk of aLC in a patient undergoing ERCP is minimized if he was operated as early as possible in the first two weeks

Aim of the workAim of the work

To evaluate the effect of To evaluate the effect of time time interval betweeninterval between LC LC andand ERCP in ERCP in patients with calcular obstructive patients with calcular obstructive

jaundice on conversion rates, jaundice on conversion rates, postoperative morbidity and postoperative morbidity and

hospital stay.hospital stay.

MethodologyMethodology

MethodologyMethodology One hundred and twenty four One hundred and twenty four

patients. patients. TheThe indications for ERCP were; indications for ERCP were; The presence of stones in common bile The presence of stones in common bile

duct at ultrasonographic examination.duct at ultrasonographic examination. Suspicion of choledocholithiasis based Suspicion of choledocholithiasis based

on the presence of certain predictors on the presence of certain predictors (jaundice, dilated CBD, elevated serum (jaundice, dilated CBD, elevated serum bilirubin and elevated alkaline bilirubin and elevated alkaline phosphatase).phosphatase).

Patients with Patients with evidenceevidence of of inflammation (inflammation (cholecystitis, cholecystitis, pancreatitis, cholangitispancreatitis, cholangitis), ), known known allergy to contrast media and possible allergy to contrast media and possible intra-abdominal adhesions were intra-abdominal adhesions were excluded from the study. excluded from the study.

Methodology Methodology (cont.,)(cont.,)

ES was performed after ES was performed after the the diagnosis ofdiagnosis of obstructive obstructive choledocholithiasis choledocholithiasis hashas been been established byestablished by ERCP. ERCP.

Then, theThen, the patients were randomly patients were randomly classified equally into;classified equally into;

The first group (Early group)The first group (Early group),, LC was LC was performed within 72 hours. performed within 72 hours.

The second group (delayed group)The second group (delayed group),, LC LC was performed after was performed after 6 weeks6 weeks. .

ResultsResults

Results (cont.,)Results (cont.,)

Age differences between the two groupsAge differences between the two groups

40

40.5

41

41.5

42

42.5

43

Average age (years)

Early

Delayed

42.6

40.9

Results (cont.,)Results (cont.,)

Sex differences between the two groupsSex differences between the two groups

0

10

20

30

40

50

60

70

80

90

100

Male Female

Early

Delayed

Results (cont.,)Results (cont.,)

Lab results in the two groups Lab results in the two groups

0102030405060708090

Elevated Bilirubinlevel

Elevated serumALP level

Elevated serumGGT level

Early

Delayed80.6

%74.2%

83.9%77.4%

38.7%

32.3%

Results (cont.,)Results (cont.,)

Findings in UltrasoundFindings in Ultrasound

0

10

20

30

40

50

60

70

80

90

Dilated CBD CBD stone

Early

Delayed

82.3%75.8

%72.6

%67.7%

Results (cont.,)Results (cont.,)

Conversion rateConversion rate

0

5

10

15

20

25

conversion rate

Early

Delayed

22.6%

6.5%

Results (cont.,)Results (cont.,)

Early groupEarly groupDelayed Delayed groupgroup

Duration of Duration of operation operation (min)(min)**

42.342.3 10.6 10.672.272.216.816.8

Postoperative Postoperative hospital stay hospital stay (days)(days)**

1.11.1 1.9 1.93.53.51.21.2

Results (cont.,)Results (cont.,)

Postoperative complicationsPostoperative complications

0

2

4

6

8

10

12

wound infection fever

Early

Delayed

11.3%

8.1%8.1%

3.2%

DiscussionDiscussion

During the last three decades, major advances in the management of CBD stones have been

developed .

ERCP is now widespread and some physicians considered it as a routine step to attain ductal clearance before LC.

Few studies have investigated the time

interval between the two procedures and produce conflicting results .

Some studies found that short interval is associated with fewer complications and lower conversion rate

to open cholecystectomy while others found no association .

In the present study; we evaluated the In the present study; we evaluated the difference difference between patients who underwent LC within between patients who underwent LC within 72 hours 72 hours after ERCP and those who underwent LC after ERCP and those who underwent LC after 6 weeks after 6 weeks of ERCP. The first 72 hours was chosen of ERCP. The first 72 hours was chosen because the because the possible inflammatory process produced by possible inflammatory process produced by ERCP ERCP should be at its start without formation of should be at its start without formation of adhesions or adhesions or development of oedema while after 6 weeks development of oedema while after 6 weeks the oedema the oedema subsided and adhesions may be improved or subsided and adhesions may be improved or completely completely resolved.resolved.

The present study showed that 22.6% of patients waiting to undergo cholecystectomy after 6 weeks of ERCP had experienced at least one biliary event that require intervention.

Our results show that patients who underwent LC within 72 hours after ERCP have significantly lower conversion rate to open cholecystectomy, shorter hospital stay and shorter operation time when compared to patients who underwent LC

after 6 weeks of ERCP. The main reasons for conversion to laparotomy were extensive inflammatory adhesions and oedema while intraoperative bleeding is a less likely cause

The operating time was longer in patient underwentdelayed cholecystectomy possibly due to scarring and fibrosis of the biliary tree and Calot's triangle which make the surgeon very cautious during dissection of the junction between cystic duct, common hepatic duct and CBD.

Also patients in this group have significantly longer hospital stay than patients in the early group. This partially due to increased number of patients who underwent open cholecystectomy and the more encountered postoperative complications in the elayedgroup .

ConclusionConclusion

It is recommended to It is recommended to perform perform LCLC as early as as early as

possible within 72 hours possible within 72 hours after ERCP to decrease after ERCP to decrease the conversion rate to the conversion rate to open cholecystectomy open cholecystectomy thus decreasing the thus decreasing the

anticipated postoperative anticipated postoperative morbidity and prolonged morbidity and prolonged

hospital stayhospital stay. .

THANK YOUTHANK YOU

Prof. Gouda El-LabbanProf. Gouda El-Labban