Identifying Factors Predicting Response to Endoscopic Management of Chronic Pancreatitis Secondary to Pancreas Divisum.

INTRODUCTION: Appropriately selecting patients with chronic pancreatitis associated with pancreas divisum (PD) for endoscopic retrograde cholangiopancreatography (ERCP)-based therapy versus surgery remains difficult. The objective of this study was to identify factors that predict success or failure of ERCP for treatment of chronic pancreatitis in PD. METHODS: Patients undergoing ERCP for a diagnosis of PD and pancreatitis between 2008 and 2016 were identified and grouped according to whether they required one or two ERCPs or three or more ERCPs. Groups were compared along demographic, diagnostic, laboratory, ERCP-related, and outcome variables. RESULTS: Patients requiring 1-2 ERCPs were less likely to have back pain on initial presentation (4 vs. 24%, p = 0.02) and less likely to have a dilated bile duct on imaging prior to their first ERCP (8 vs. 30%, p = 0.04) than those requiring 3+ ERCPs. Patients requiring 1-2 ERCPs were also less likely to eventually require operative intervention for treatment of their chronic pancreatitis than those requiring 3+ ERCPs (24 vs. 44%, p = 0.047). On multivariable analysis, a dilated bile duct (odds ratio (OR) = 6.0, 95% confidence interval (CI) = 1.01-36.0, p = 0.048) was independently associated with requiring 3+ ERCPs. Back pain (OR = 6.3, 95% CI = 0.73-54.2, p = 0.09) trended toward but did not reach statistical significance for being independently associated with requiring 3+ ERCPs. CONCLUSIONS: The success of endoscopic treatment of chronic pancreatitis in patients with PD is dependent on proper patient selection. Patients with a dilated bile duct and back pain upon presentation may not respond well to endoscopic treatment alone and are more likely to eventually require operative intervention. Consideration should be given to early operative intervention in these patients.

Comparing the efficacy of initial percutaneous transhepatic biliary drainage and endoscopic retrograde cholangiopancreatography with stenting for relief of biliary obstruction in unresectable cholangiocarcinoma.

BACKGROUND: In patients with cholangiocarcinoma (CC), management of biliary obstruction commonly involves either up-front percutaneous transhepatic biliary drainage (PTBD) or initial endoscopic retrograde cholangiopancreatography (ERCP) with stent placement. The objective of the study was to compare the efficacy and of initial ERCP with stent placement with efficacy of initial PTBD in management of biliary obstruction in CC. METHODS: A single-center database of patients with unresectable CC treated between 2006 and 2017 was queried for patients with biliary obstruction who underwent either PTBD or ERCP. Groups were compared with respect to patient, tumor, procedure, and outcome variables. RESULTS: Of 87 patients with unresectable CC and biliary obstruction, 69 (79%) underwent initial ERCP while 18 (21%) underwent initial PTBD. Groups did not differ significantly with respect to age, gender, or tumor location. Initial procedure success did not differ between the groups (94% ERCP vs 89% PTBD, p = 0.339). Total number of procedures did not differ significantly between the two groups (ERCP median = 2 vs. PTC median = 2.5, p = 0.83). 21% of patients required ERCP after PTBD compared to 25% of patients requiring PTBD after ERCP (p = 1.00). Procedure success rate (97% ERCP vs. 93% PTBD, p = 0.27) and rates of cholangitis (22% ERCP vs. 17% PTBD, p = 0.58) were similar between the groups. Number of hospitalizations since initial intervention did not differ significantly between the two groups (ERCP median = 1 vs. PTC median = 3.5, p = 0.052). CONCLUSIONS: In patients with CC and biliary obstruction, initial ERCP with stent placement and initial PTBD both represent safe and effective methods of biliary decompression. Initial ERCP and stenting should be considered for relief of biliary obstruction in such patients in centers with advanced endoscopic capabilities.

Training surgeons in endoscopic retrograde cholangiopancreatography.

BACKGROUND: General surgeons commonly perform upper gastrointestinal endoscopy in practice, but few perform endoscopic retrograde cholangiopancreatography (ERCP), partly because of limited training opportunities. This report focuses on the value of an ERCP fellowship training program to a broad-based, mature residency in surgery and our observations on the experience required for surgeons to be trained in advanced interventional ERCP. METHODS: Since the program was initiated in 1992, 13 ERCP fellows have been trained for individual periods of 6 to 14 months. This study investigated all procedures with fellow involvement (2,008 cases) from among a total experience of 3,641 ERCPs. Data collected included type of ERCP (diagnostic/therapeutic), fellow success in cannulating the duct of interest, and faculty success in cases of fellows who failed. Of the 13 fellows, 9 had previous endoscopy experience, but none had training in ERCP. RESULTS: An 85% cannulation rate was accepted as successful, and cannulation rates for each fellow were calculated for each 3-month period. The 85% mark was reached by 4 (31%) of 13 fellows in the first period, 2 of 13 fellows (15%) in the second period, 5 of 11 fellows (45%) in the third period, 7 of 10 fellows (70%) in the fourth period, and 1 of 1 fellow (100%) in the fifth period of training. On the average, it took 7.1 months and 102 ERCPs for trainees to reach desired success levels. Success came more promptly with prior exposure to endoscopy. Fellows without prior endoscopic experience required 148 cases to reach 85% success. Resident surgical experience with major pancreatic resections increased threefold after establishment of the fellowship. CONCLUSIONS: Training in ERCP is possible within the scope of a surgical fellowship in a reasonable length of time and experience. Complication rates remain low even with fellow involvement. Establishment of an ERCP program increases the focus and experience of pancreas surgery in a surgical residency for chief residents.

Role of pancreatic duct stenting in the treatment of chronic pancreatitis.

BACKGROUND: Endoscopic retrograde cholangiopancreatography and stent placement are relatively new alternatives to surgery for the treatment of chronic pancreatitis. The objective of this study was to determine the efficacy of pancreatic duct stent placement for the treatment of chronic pancreatitis. METHODS: This study included 89 patients treated with pancreatic stents between 1993 and 2002. The patients were contacted via telephone for a personal interview with regard to pain, medication usage, weight loss or gain, and eating patterns. Additionally, medication usage before and after treatment was documented from the Kentucky Cabinet for Health Services' electronic reporting system for narcotic use. RESULTS: Of the 89 patients, 9 were deceased, 5 either refused to interview or could not be contacted, and 75 were interviewed. Significant weight gain exceeding 15 lb after treatment was experienced by 22%, whereas only 4% lost weight. A majority of the patients (68%) noted that they had less severe relapses or no relapses after treatment. The patients reported a decrease in pain level on a 10-point scale from 8.7 to 4.1 (53% decrease) after treatment. A decrease in pain medication usage was reported by 47% of the patients, and 83% considered their treatment successful. The Kentucky All Schedule Prescription Electronic Report (KASPER) was obtained before and after treatment for 55 patients. According to this statewide electronic reporting system, 63% had a documented decrease in narcotic use. CONCLUSION: The findings of this study support the use of pancreatic duct stenting as an option before surgical intervention for these difficult-to-manage patients with chronic pancreatitis.

Cost comparison of endoscopic stenting vs surgical treatment for unresectable cholangiocarcinoma.

BACKGROUND: Total lifetime costs of endoscopic vs surgical treatment for obstructive jaundice due to cholangiocarcinoma are difficult to assess. The purpose of this study was to compare total costs in these two groups, including all treatment and retreatments. METHODS: This retrospective study identified patients with biopsy-proven cholangiocarcinoma treated this decade with either endoscopic biliary stenting or surgical biliary-enteric bypass with or without resection. Outcomes and hospital charges were recorded. Ten matched control patients were compared from each group. Costs included those for cost of repeat endoscopy in the endoscopic group and for the management of recurrent obstructive jaundice in the surgical group. RESULTS: The groups were similar in age and gender ratio. The surgical approach was frequently for cure; therefore, surgical patients were by and large at an earlier stage of their disease than those in the endoscopic group. Mean survival for the endoscopic group was 19 months vs 16.5 months for the surgical group. The median total lifetime cost for surgical therapy was $60,986 vs $24,251 for endoscopic therapy. CONCLUSION: Endoscopic therapy is an effective palliative therapy for unresectable cholangiocarcinoma. Endoscopic therapy for this entity costs significantly less than surgical treatment. The cost benefit of endoscopic stenting over standard surgical bypass in the management of patients with unresectable cholangiocarcinoma, when considered along with its minimally invasive approach, makes this the procedure of choice for palliative therapy.

Interventional endoscopic retrograde cholangiopancreatography and endoscopic surgery.

Interventional endoscopic techniques have been indespensible in almost every area of modern surgery. As surgeons, we need to continue to advance our skills in these areas if we expect to continue to be involved in these aspects of patient care.

Bile duct carcinoma: trends in treatment in the nineties.

Surgical resection provides the only known chance of cure for cholangiocarcinoma, and even then the 5-year survival is only 10 to 20%, and only one-third of patients are resectable for cure at the time of diagnosis. In recent years we have had considerable experience with endoscopic stenting to palliate common bile duct cancers. This has prompted us to evaluate our results for both endoscopic and surgical treatment of cholangiocarcinoma. From January 1990 through June 1999, we reviewed our endoscopic retrograde cholangiopancreatography registry and the hospital records for patients we treated for cholangiocarcinoma. Fifty patients were identified: 45 with cholangiocarcinoma and five with gallbladder cancer (who were excluded). The surgical group consisted of 16 patients: in 14 patients, resection for cure was possible whereas two had palliative procedures. There was one mortality (6%) and the median survival was 16 months. There have been no long-term surgical survivors, but 2 patients are alive at 24 months. We treated 29 patients with advanced disease with endoscopic stents (the endoscopic group) mainly for relief of obstructive jaundice. Six of 29 patients in the endoscopic group were critically ill and died in less than 4 weeks, whereas 23 patients who were in better condition survived for a mean of 10 months (range 2-84 months). We conclude that for common duct bile cancer surgical resection remains the treatment of choice but is applicable in only 30 to 35 per cent of cases. Endoscopic stenting effectively relieves jaundice and can provide long-term palliation comparable with surgical bypass; 12 of 29 patients in our endoscopic group survived 12 months or longer, and one is alive at 84 months after initial stenting.

Endoscopic treatment of distal bile duct stricture from chronic pancreatitis.

BACKGROUND: Endoscopic placement of biliary stents is an effective initial treatment for jaundice and cholangitis caused by common bile duct (CBD) strictures secondary to chronic pancreatitis; however, the role of endoscopic treatment for long-term management of these strictures is less clear. In 1992, we designed a protocol of balloon dilatation and stenting for > or =12 months. This study evaluates endoscopic therapy as a definitive long-term treatment for these strictures. We have treated 25 patients with this protocol. METHODS: All patients had an endoscopic sphincterotomy, balloon dilatation of the stricture, and then placement of a polyethylene stent (7-11.5 F). Stents were exchanged at 3-4-month intervals to avoid the complications of clogging and cholangitis. We were particularly interested in how many patients would achieve resolution of the stricture and tolerate removal of the stent. RESULTS: The length of the CBD strictures ranged from 8 to 40 mm. Within days of stenting, all patients achieved relief of jaundice and cholestasis. Complications consisted of six episodes of cholangitis and nine episodes of pancreatitis. There were no deaths. Twenty of the 25 patients are now stent-free after an average stenting period of 13 months (range, 3-28). To date, there has been no recurrence of stricture, for a mean of 32 months. Three patients still have stents in place, and two patients required operation--one for persistent stricture and recurrent cholangitis after 8 months of stenting, and one for a mass in the head of the pancreas that was thought to be cancer. CONCLUSIONS: Our results indicate that these strictures will respond and dilate after a course of stenting in 80% of patients, with an acceptable morbidity. Although these are medium-term results at 32 months, we would expect most recurrences within the 1st year following stent removal. In some cases, stenting is necessary for >12 months. Thus, the data suggest that endoscopic stenting provides definitive treatment in most patients with CBD stricture due to chronic pancreatitis and may be considered a viable alternative to standard surgical bypass.

Endoscopic drainage of the pancreatic pseudocyst.

BACKGROUND: Pancreatic pseudocyst is a common complication of chronic pancreatitis occurring in 20% to 40% of cases. Pseudocysts can be treated by endoscopic cystenterostomy or transpapillary drainage, percutaneously with computed tomography guidance or operatively. METHODS: A total of 36 endoscopic pancreatic pseudocyst drainage procedures were performed in 29 patients with 34 pseudocysts. Eighty percent presented with chronic pain, 25% had recurrent pancreatitis, and approximately one half of the patients had either gastric outlet obstruction or a palpable abdominal mass. RESULTS: Thirty-six endoscopic drainage procedures were performed, 27 cystenterostomies and 9 transpapillary drainages. Endoscopic treatment achieved complete resolution of the pseudocyst in 24 of 29 patients (83%), and the other 5 (17%) eventually required surgery. Two patients required distal pancreatectomy because of their pancreatic pathology, 2 cystgastrostomies for persistence of the pseudocyst, and 1 external drainage of an infected pancreatic cyst. The mean follow-up after the initial drainage was 16 months. There were no deaths attributed to the procedures and no complication that required surgery. Only 1 nonadherent pseudocyst (cystadenoma) required immediate operation after attempted endoscopic drainage. CONCLUSIONS: The conclude that endoscopic drainage of pancreatic pseudocysts can be both safe and effective, and definitive treatment. It should be considered as an alternative option before standard surgical drainage in selected patients.

Selective role for endoscopic retrograde cholangiopancreatography in abdominal trauma.

BACKGROUND: Emergency endsocopic retrograde cholangiopancreatography (ERCP) is rarely indicated in trauma patients; however, in cases of suspected pancreatic or bile duct injury or bile leak, it may be useful. The purpose of this paper is to review our ERCP experience in trauma patients. Our Level I Trauma Center admits 1800 patients annually. METHODS: Since January 1991, we have performed ERCP in 12 trauma patients, nine after blunt injury and three after penetrating injury. RESULTS: ERCP was used as a diagnostic tool to evaluate the pancreatic duct in six stable patients with equivocal CT scans and unexplained abdominal pain, fever, and an elevated amylase or a peripancreatic pseudocyst. Based on their ERCP findings-one intact pancreatic duct, one transected duct, and four pseudocysts-five of the six patients had operations. We performed ERCP in six patients for persistent bile leaks (five cases) or jaundice (one case). The findings were one case of bilemia (intrahepatic biliovenous fistula), one case of common bile duct disruption, and four cases of persistent bile leaks from the liver after liver injuries. Endobiliary stents placed in five patients successfully stopped the four bile leaks and closed the biliovenous fistula. The one case of ductal disruption required an open choledochojejunostomy. The only ERCP complication was an episode of cholangitis treated with antibiotics. The earliest ERCP was 3 days after injury, and most were performed within 2 months. CONCLUSIONS: ERCP is a helpful procedure for diagnosing biliary and pancreatic duct injury in a select group of trauma patients who do not have obvious indications for exploration. In addition, ERCP techniques are also effective for treating most bile leaks.

Management of malignant biliary stricture with self-expanding metallic stent.

BACKGROUND: Self-expanding metallic mesh stents are designed to remain patent longer than polyethylene (PE) stents, which generally clog in 3 to 4 months. Though more expensive, metal stents may therefore be a better choice for malignant strictures. METHODS: From January 1991 to October 1995, we performed ERCP in 212 patients with malignant or benign strictures, and 34 ultimately had insertion of a metallic stent. These stents were placed by the percutaneous transhepatic route in 17 patients and endoscopically in 17. RESULTS: Metallic stent insertion was successful in each case and relieved the preoperative jaundice and cholangitis. There were no procedure-related deaths; complications were pancreatitis (one) and hemorrhage (one). Overall stent patency was 6.2 months. Three of 34 stents occluded due to tumor ingrowth at 3, 4.5, and 8 months and were treated by placing a new PE stent through the blocked metal stent. The remaining 31 stents remained patent until patient death (n = 15, mean survival = 4.9 months) or are still open (n = 16, mean patency = 12.2 months). CONCLUSIONS: Self-expanding metal stents provide effective palliation of malignant biliary strictures and should be considered an alternative to open surgery. Metal stents remain patent much longer than PE stents and usually a single session of metal stenting can palliate biliary obstruction for life.

Endoscopic management of benign and malignant biliary strictures.

BACKGROUND: It is now possible to manage most extrahepatic bile duct strictures, benign or malignant, using endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic dilatation and stenting. METHODS: Over a 5-year period we treated 218 patients with strictures of extrahepatic bile ducts. Eighty-six patients had benign biliary stricture. Endoscopic treatment was performed in 67 (78%) of these patients. Open surgical biliary drainage was preferred in 12 patients (14%), and 7 patients (8%) were managed conservatively without stenting or surgery. One hundred and thirty-two patients had malignant biliary stricture. One hundred and one patients (77%) underwent endoscopic stent placement. Thirty-one patients (23%) underwent surgery for potential curative resection after diagnostic ERCP. The average life span in the malignant stricture group was 5 months (range 0.1 to 25 months) after the initial endoscopic procedure. RESULTS: Altogether 313 endoscopic procedures in 218 patients were performed for benign and malignant bile duct strictures. Complications included hemorrhage in 8 (3%), pancreatitis in 10 (3%), and suspected retroperitoneal perforation in 2 (0.6%). There were no ERCP related deaths; one patient died of uncontrolled bleeding from transhepatic stenting. In benign strictures, there has been no recurrence of strictures after the last stent removal with a mean followup of 21 months (range 0.1 to 31 months). All complications were successfully treated conservatively. CONCLUSIONS: Endoscopic management of benign and malignant biliary stricture is possible with minimal morbidity and mortality and should be considered an acceptable option to surgical management.

Peritoneal host defenses are less impaired by laparoscopy than by open operation.

There is a growing body of evidence that laparoscopic surgery is physiologically less injurious than open surgery. We hypothesized that the open technique results in a greater impairment of peritoneal and systemic defense mechanisms than does the laparoscopic technique. Nissen fundoplication, standardized in technique and duration, was performed in 16 pigs. The procedure was performed through a standard midline incision (OPEN, n = 8) or with laparoscopic technique and CO2 pneumoperitoneum (LAP, n = 8). The peritoneal cavity was instilled with 400 cc of normal saline, either alone (not contamined, n = 8) or containing 10(9) E. coli/ml (contaminated, n = 8). Quantitative cultures, cell count, and flow cytometry were performed on blood and peritoneal fluid samples obtained at timed intervals. We found that host defense processes were better preserved after LAP than by OPEN surgery. Peritoneal and systemic monocyte class II antigen expression, and serum tumor necrosis factor-alpha activity was greater in the OPEN group compared with the LAP group, but peritoneal bacterial clearance was more efficient in the LAP group. These data may illustrate a potential benefit of laparoscopic surgery in cases of peritoneal contamination.

The role of bile acid secretion in the hepatic response to operation and infection.

Hepatic function is altered in many surgery-related diseases. Bile acid secretion is the major determinant of bile formation and an important indicator of overall hepatic function. To investigate the cause of intrahepatic cholestasis, which is frequently associated with sepsis, we studied the effects of cecal ligation and puncture (CLP) and surgical stress on bile acid secretion and composition. CLP or a sham operation was performed on 20 male Sprague-Dawley rats. Bile was collected from each rat by cannulation of the common bile duct for 10-minute intervals, at 5 and 20 hours after the initial procedure. Bile acid analysis was then performed by high performance liquid chromatography (HPLC). In CLP rats, there was a significant (P < 0.05) cholestatic effect. Bile flow was reduced to 70 +/- 13 per cent at 5 hours, and to 55 +/- 16 per cent at 20 hours (per cent of the sham mean value). In the sham-operated rats, there was a significant choleresis at 20 hours. Bile flow was increased to 146 +/- 13 per cent; bile acid secretion to 245 +/- 24 per cent; and total bile acid concentration to 175 +/- 19 per cent of the sham 5-hour value (P < 0.05). This increased secretion was significantly greater in the metabolites of chenodeoxycholate. However, these surgical stress-associated changes in bile acid secretion and composition did not occur in CLP rats. These findings are consistent with surgical stress-induced induction of 7 alpha-hydroxylase, which was not found in the septic animals. These observations may provide useful insights into the early stages of the pathogenesis of sepsis-related hepatic dysfunction and failure.

Acute biliary pancreatitis. The roles of laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography.

Since January 1990, we have treated 113 patients for gallstone pancreatitis; 59 with laparoscopic cholecystectomy (LC), 50 with open cholecystectomy, and 4 with ERCP/sphincterotomy only. In the LC group, 47 had LC during the index admission and 12 underwent delayed LC. Fifty patients had open cholecystectomy, 47 during the index admission. ERCPs were performed in 43 of the 113 patients; CBD stones were identified in 19/43 (44%) and removed endoscopically in 18 (95%). The ERCP complication rate was 6.5%. In total, CBD stones were identified in 29/113 patients (26%). Patients who had imaging of the CBD within the first 4 days from onset of symptoms were more likely to have stones identified than were those patients who were studied after 5 days. Recurrent pancreatitis occurred in in five of 11 patients (45%) who had a > or = 30-day delay to definitive treatment. We conclude that LC can be safely performed in most patients during the index admission for gallstone pancreatitis. This policy should reduce the 30-50% risk of recurrent pancreatitis associated with a delayed operation. ERCP is a helpful adjunct for CBD stones.

Use of endoscopic retrograde cholangiopancreatography in the management of biliary complications after laparoscopic cholecystectomy.

BACKGROUND: Current options in the management of bile duct injuries caused by laparoscopic cholecystectomy include diagnostic and therapeutic endoscopic retrograde cholangiopancreatography (ERCP) and open laparotomy with direct repair. The goal of this review was to clarify the role and evaluate the potential of endoscopic techniques to diagnose and treat bile duct injuries. METHODS: The records of all patients undergoing biliary tract surgery at our hospitals for the period from December 1989 to February 1993 were reviewed. Twenty-five patients were identified with bile duct injuries during laparoscopic cholecystectomy. RESULTS: ERCP was performed for diagnostic or therapeutic purposes in 22 of the 25 patients; successful opacification of the biliary tree was achieved in 21 (95%) of the 22 patients. In these 21 patients the location and nature of the injury were identified correctly in 19 (90%). In six of the 25 cases, interventional ERCP was used as the primary treatment of these injuries. Successful treatment was achieved in five (83%) of the six cases, although laparotomy was required in two to drain the abscess cavity better. Open surgical repair was performed as the primary treatment in the remaining 19 patients. Interventional ERCP with stenting was required in six and transhepatic stenting in one of these patients as an adjunctive treatment for stricture or persistent fistula. Six (86%) of these seven patients have been treated successfully to date in this manner. CONCLUSIONS: ERCP is a uniquely helpful diagnostic and therapeutic technique in the management of laparoscopic biliary complications. Open surgical repair remains the procedure of choice for patients with loss of bile duct tissue or long complex strictures. ERCP with sphincterotomy, balloon dilatation, and stenting is an accepted alternative approach for bile leaks (fistulas) and treatment of shorter strictures resulting from either the initial laparoscopic injury or the initial repair.

Complement 5a induces in vivo synthesis of cysteinyl leukotrienes in rats.

The complement derived anaphylatoxin complement 5a (C5a) is suggested to be involved in the pathogenesis of various types of diseases including endotoxic or anaphylactic shock. Studies in our laboratory demonstrated a marked and sustained reduction in renal blood flow and glomerular filtration rate after infusion of a low dose of recombinant C5a (rC5a). Renal rC5a effects were inhibited by leukotriene (LT) and thromboxane antagonists suggesting that the effects were mediated by LT. To elucidate the mechanisms of C5a effects, we monitored the biliary excretion rate of the stable metabolite, N-acetyl-LTE4, by reversed phase high performance liquid chromatography (HPLC). Rats in the experimental group were administered rC5a intravenously at 0.5 micrograms/min for 10 min. Biliary N-acetyl-LTE4 excretion was significantly increased following rC5a infusion, 0.03 ng/microliters bile to 0.129 ng/microliters. The bile flow in the experimental group was reduced about 39% by rC5a, while bile flow of the control group increased by 20% during the observation period. Infusion of rC5a resulted in an increase of arterial hematocrit from 44.7% to 48.7%, whereas blood pressure was not significantly altered in experimental and control groups. Our results suggest the in vivo effects of C5a to be mediated by cysteinyl leukotrienes, which may be important in the pathogenesis of septic, anaphylactic or traumatic shock.

The use of ERCP in the management of common bile duct stones in patients undergoing laparoscopic cholecystectomy.

The purpose of this study was to evaluate the indications and results of endoscopic retrograde cholangiopancreatography (ERCP) for gallstone disease since the advent of laparoscopic cholecystectomy. In our personal series of 410 consecutive cases of laparoscopic cholecystectomy, we found 17 common bile duct (CBD) stones; seven were identified by preop ERCP, nine at laparoscopy by intraoperative cholangiography, and one postop by ERCP. We have performed preop ERCP in 21 patients (5.1%); CBD stones were found in seven. Our indications for preop ERCP were elevated liver function tests, dilatation of the common duct by ultrasound, or a history of jaundice/pancreatitis, and all stones were successfully removed by endoscopic sphincterotomy. At laparoscopic cholecystectomy nine patients were found to have stones; one was treated with laparoscopic methods, four with open CBD exploration, and four by postop endoscopic sphinecterotomy. Post-laparoscopic cholecystectomy, five patients underwent ERCP for pain or increased liver function tests suggestive of common duct stones. One of the five was found to have stones and these were successfully removed by endoscopic sphincterotomy. ERCP is very useful as a diagnostic and therapeutic modality in laparoscopic cholecystectomy patients with suspected CBD stones. Elevated liver function tests and dilated CBD by ultrasound are the most accurate predictors of stones. Endoscopic sphincterotomy is a more effective route, at present, for stone removal than a laparoscopic approach.