Intraoperative versus postoperative rendezvous endoscopic retrograde cholangiopancreatography to treat common bile duct stones during cholecystectomy.

BACKGROUND AND AIM: The rendezvous postoperative endoscopic retrograde cholangiopancreatography (ERCP) technique has been introduced as a modification of the single-session rendezvous intraoperative ERCP procedure in the management of concurrent common bile duct stones during cholecystectomy. There are no reports on the impact of this modified technique on post-ERCP morbidity. The objective of the present study was to study and compare the rendezvous techniques in terms of procedure-associated morbidities, such as post-ERCP pancreatitis and postoperative infections. METHODS: The Swedish National Registry for Gallstone Disease and ERCP was searched for ERCP procedures cross-matched with cholecystectomies for the same patient carried out for gallstone indications between 2008 and 2014. A total of 1770 rendezvous ERCP procedures were retrieved and included in this study. The ERCP procedures were considered rendezvous intraoperative or rendezvous postoperative, depending on whether the ERCP procedure was carried out during or after completing the cholecystectomy. RESULTS: There were 1205 and 565 ERCP procedures in the rendezvous intraoperative and the rendezvous postoperative groups, respectively. The cohorts were similar in age and gender distribution. Overall complication rates were higher in the rendezvous postoperative group compared with the rendezvous intraoperative group (19.7% vs 14%, P = 0.004), involving specifically post-ERCP pancreatitis (6.4% vs 3.2% P = 0.003) and postoperative infections (4.4% vs 2.3% P = 0.028). Despite similar stone clearance rates, there were higher rates of retained stones in the rendezvous postoperative group (5.5% vs 0.6%, P < 0.001). CONCLUSIONS: Single-session rendezvous intraoperative ERCP is superior to the rendezvous postoperative ERCP technique in terms of post-ERCP pancreatitis and postoperative infections.

Index versus delayed cholecystectomy in mild gallstone pancreatitis: results of a randomized controlled trial.

BACKGROUND: Delayed cholecystectomy is associated with increased risk of biliary events. The objectives of the study were to confirm the superiority of index cholecystectomy over delayed operation in mild gallstone pancreatitis. METHODS: Patients with mild gallstone pancreatitis were randomized into index-or delayed cholecystectomy (IC vs. DC). IC was performed within 48 h from randomization provided a stable or improved clinical condition. The primary outcome was gallstone-related events. Secondary outcomes were rates of cholecystectomy complications, common bile duct stones (CBDS) detected at cholecystectomy and patient reported quality-of-life and pain. RESULTS: Sixty-six patients were randomized into IC (n = 32) or DC (n = 34) between May 2009 and July 2017. There were significantly higher rates of gallstone-related events in the DC compared with the IC group (nine patients vs. one patient, p = 0.013). No statistically significant differences could be demonstrated in cholecystectomy complications (p = 0.605) and CBDS discovered during cholecystectomy (p = 0.302) between the groups. Pain and emotional well-being measured by SF-36 were improved significantly in the IC group at follow-up. CONCLUSIONS: Delayed cholecystectomy in mild gallstone pancreatitis can no longer be recommended since it is associated with an increased risk for recurrent gallstone-related events and impaired patient's reported outcomes. TRIAL REGISTRATION NUMBER: clinicaltrials.gov (ID: NCT02630433).

Regional variations in cholecystectomy rates in Sweden: impact on complications of gallstone disease.

OBJECTIVE: There are considerable variations in cholecystectomy rates between countries, but it remains unsettled whether high cholecystectomy rates prevent future gallstone complications by reducing the gallstone prevalence. The aims of this study were to investigate the regional differences in cholecystectomy rates and their relation to the incidence of gallstone complications. MATERIAL AND METHODS: Nation-wide registry-based study of the total number of cholecystectomies in Sweden between 1998 and 2013. Data were obtained from the Swedish Inpatient Registry covering the entire population and subdivided for by the 21 different counties. Indications for the procedure were prospectively collected during the years 2006-2013 in the National Registry for Gallstone Surgery and ERCP. The detailed demography of the total number of patients undergoing cholecystectomy and its relation to the respective indications were analysed by linear regression. RESULTS: The annual rates of cholecystectomy in the Swedish counties ranged from 100 to 207 per 100,000 inhabitants, with a mean of 157 (95% CI 145-169). The majority of cholecystectomies were done in females based on the indication biliary colic, with a peak incidence in younger ages. Cholecystectomies performed due to gallstone complications, pancreatitis and cholecystitis, were mainly carried out in the older age groups. No significant relationship could be demonstrated between cholecystectomy rates in the different regions and the respective incidences of gallstone complications. CONCLUSIONS: There are wide regional variations in cholecystectomy rates in Sweden. The present study does not give support that frequent use of cholecystectomy in uncomplicated gallstone disease prevents future gallstone complications.

Outcome of probe-based confocal laser endomicroscopy (pCLE) during endoscopic retrograde cholangiopancreatography: A single-center prospective study in 45 patients.

BACKGROUND: Diagnosis of pre-malignant and malignant lesions in the bile duct and the pancreas is sometimes cumbersome. This applies in particular to intraductal papillary mucinous neoplasia (IPMN) and bile duct strictures in primary sclerosing cholangitis (PSC). AIMS: To evaluate in a prospective cohort study the sensitivity and specificity of probe-based confocal laser microscopy (pCLE) during endoscopic retrograde cholangiopancreatography (ERCP). METHODS: We performed pCLE together with mother-baby endoscopy (SpyGlass) during 50 ERCP sessions in 45 patients. The Miami and Paris criteria were applied. Clinical diagnosis via imaging was compared to pCLE and the final pathological diagnosis from surgically-resected, biopsy, or cytology specimens. Patients were followed up for at least 1 year. RESULTS: We were able to perform pCLE in all patients. Prior to endoscopy, the diagnosis was benign in 23 patients and undetermined (suspicious) in 16 patients, while six patients had an unequivocal diagnosis of malignancy. Sensitivity was 91% and specificity 52%. The positive (PPV) and negative predictive value (NPV) was 82% and 100%, respectively. Apart from mild post-ERCP pancreatitis in two patients, no complications occurred. CONCLUSIONS: Our study showed that pCLE is a safe, expert endoscopic method with high technical feasibility, high sensitivity and high NPV. It provided diagnostic information that can be helpful for decisions on patient management, especially in the case of IPMN and unclear pancreatic lesions, in individuals whom are at increased risk for pancreatic cancer.

A 10-year study of rendezvous intraoperative endoscopic retrograde cholangiography during cholecystectomy and the risk of post-ERCP pancreatitis.

BACKGROUND: Rendezvous intraoperative endoscopic retrograde cholangiography (RV-IOERC), also called guidewire-facilitated IOERC, is one of the single-stage options available for managing common bile duct stones (CBDS) during laparoscopic cholecystectomy. The objective of this study is to investigate procedure-related complications in IOERC patients and stone clearance. METHODS: All patients who underwent IOERC between January 2000 and December 2009 were identified from the local registry of Karolinska University Hospital in Huddinge. Medical charts and ERC reports were studied, and descriptive statistics were obtained. Outcomes were procedure-related complications, especially post-ERCP pancreatitis (PEP), stone clearance, and mortality. RESULTS: 307 patients were identified. In 264 of the patients, the rendezvous cannulation technique was successful (86 %); in the remaining 43 patients, conventional cannulation technique was necessary. In total, PEP occurred in seven patients (2.28 %). One of the PEP patients was in the rendezvous cannulated group (0.37 %), whereas six patients developed PEP in the nonrendezvous group (13.95 %, p < 0.001). The primary stone clearance rate was 88.27 % (271/307). There was no mortality within 90 days in the series. CONCLUSIONS: IOERC with RV cannulation technique for management of CBDS during laparoscopic cholecystectomy has a low PEP rate and a high stone clearance rate, making it a safe and feasible method for removing CBDS. However, the technique requires logistics to perform IOERC in the operating theater. The present data suggest that IOERC with RV cannulation is superior to conventional cannulation with respect to risk of PEP.