HPBSurgery, 1995, Vol. 8, pp. 187-192
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ERCPFollowingLaparoscopic
Cholecystectomy: A Safe and Effective way to
Manage CBD Stones and Complications
COLLEEN M. SCHMITT*, JOHN BAILLIE* and PETER B. COTTON
* Division ofGastroenterology, University ofTennessee, Chattanooga, Tennesse; Division ofGaproenterocopy, Duke University
Medical Center, Durham, North Carolina; Division ofGastroenterology, Medical University of South Carolina, Charleston,
South Carolina
The efficacy ofERCP in detecting and treating post-laparoscopic cholecystectomy problems was
examined in a series ofconsecutive patients undergoingdirected examination ofthe biliary tree over a
two-year period. Three major diagnostic groups were identified: leaks and bile duct injuries (n 9),
retained common bile duct stones (n 18), and post-cholecystectomy pain (n 13). These diagnostic
groups differed in degree of abnormal bilirubin (p .004) and time between surgery and ERCP
(p .0005). Diagnosis ofa post-operative complication was successful in 92% ofattempted cases.
Therapy was successful in 92% ofattempted cases. Three patients developed mild pancreatitis as a
result ofERCP. This series underscores the efficacy ofa multi-disciplinary approach to problems
which occur after laparoscopiccholecystectomy.
KEYWORDS: Laparoscopiccholecystectomy complications endoscopic retrograde
cholangiopancreatography bile duct bile duct stricture
INTRODUCTION
Laparoscopic cholecystectomy (LC) is the new gold stan-
dard for surgical treatment of symptomatic gall bladder
diseaseI. Despite the absence ofcontrolled trials compa-
ring this relatively new procedure with standard open
cholecystectomy (OC), LC is widely accepted because
ofdecreased hospital stay, swift return to normal activi-
ties, reduced post-operative pain, and better cosmetic
results2-4.
With the rapid endorsement of LC, the role of the
biliary endoscopist in diagnosis and management oftwo
major post-operative problems is increasing. The most
important ofthese is bile duct injury. Regional experiences
with LC have demonstrated an increased rate ofbile duct
injury compared with OC. This rate appears dispropor-
tionately high in the early experience of the surgeon5-7.
The second dilemma is retained common bile duct stones
which require removal. Patients with these post-operative
problems may be referred to the biliary endoscopist for
diagnosis or therapy.
Addressfor correspondence." Box 3515, Duke University Medical
Center, Durham, NC 27710
We report our experience in diagnostic and therapeutic
ERCP in 52 consecutive patients referred to our endo-
scopy unit at a tertiary medical center following LC.
MATERIALS ANDMETHODS
Patients were identified by a retrospective review of the
Duke University Medical Center (DUMC) Gastro-
intestinal Endoscopy Database. Data were collected by
chart abstraction and telephone interview for a 2 year
period between March 1990 through February 1992.Cri-
teria for entry were: (1) previous LC or LC conversion to
OC, and (2) referral specifically for examination of the
biliary tree. Demographic data included age, gender, and
referral area. Operative data included results of intra-
operative cholangiogram (ifperformed), and whethercon-
version to OC was required. Pre-ERCP data included
number of days from surgery until referral, type of sy-
mptoms (e.g., fever, abdominal pain, fistulous drainage),
requirement for percutaneous drainage ofa biloma, and
elevation ofliver chemistries (upper limit ofnormal: AST
45 u/l, ALT 45 u/l, AP 110 u/l, TB 1.2 mg/dl). ERCPdata
included type of therapeutic procedure(s) performed,
number of procedures required to complete therapy,
187
188 C.M. SCHMITT et aL
duration ofstenting, and type and outcome ofother inva-
sive therapy required (percutaneous or surgical). Success
of therapeutic ERCP was defined as (1) avoidance of
surgical correction, and (2) resolution ofthe specific pro-
blem leading to the procedure (e.g., resolution ofleak or
stricture, removal of retained common bile duct (CBD)
stones). Complications were defined according to Cotton
et al. Statistical tests were performed using nonpa-
rametric methods (Wilcoxon R.ank Sum test and Kruskal-
Wallis test for multiple groups) as data were not assumed
to have normal distribution.
Table 3 Liver chemistries by diagnostic group, median (range)
Group Group2 Group3 Overall
n= 18 n= 18 n= 14 n=52
AST"
ALT
Ap
TB
36 (5-265) 61 (12-400)' 37 (8-81) 43 (5-400)
46 (1-440) 75 (7-428) 32 (11-112) 51 (1-440)
162 (52-678) 172 (55-575) 111 (55-391) 162 (52-678)
0.8 (0.3-6.0) 2.2 (0.2-9.0) 0.6 (0.1-1.9) 0.8 (0.1-9.0)
p .09, Kruskal-Wallis
p .07, Kruskal-Wallis
not statistically significant, p .38, Kruskal-Wallis
p .004, Kruskal-Wallis
RESULTS
During this 2 year period, 58 patients were referred to the
DUMC biliary endoscopy service. Six patients were exclu-
ded for examination not directed at the bile duct (n 5)
and routine follow-up of primary sclerosing cholangitis
(n 1). Fifty-two patients were included for study.
There were 19 males and 33 females. Median age was
43.5 years (range, 16-93 years). LC had been performed
outside DUMC in 36 cases (69.2%). For the purposes of
this review, patients were categorized into three major
diagnostic groups: Group leaks and bile duct injuries,
Group 2 retained CBD stones, and Group 3 post-
cholecystectomy pain (post-LC pain) (Table 1). Patients
most commonly presented with abnormal liver chemistries
and abdominal pain (Table 2). Liver chemistries were
elevated in 81% of patients with median (range), AST
43 u/1 (5-400), ALT 51 u/I (1-440), AP u/1 162 (52-678), TB
Table Diagnosis at ERCP by major diagnostic group (n 50)"
N (%)
Group Injuries 19 (38)
Leaks(12)
Strictures (7)
Group 2 Retained CBD stones 18 (36)
Group 3 Post-LC pain 13 (26)
SOD (2)
Pancreatitis
Normal(10)
Two patients failed diagnostic ERCP
Table 2 Clinical presentation (n 52)"
(%)
Abnormal liver chemistries 42
Abdominal pain 22
Abnormalcholangiogram
Percutaneous drainage of fluid collection 11
Known or suspected injury at the time of surgery 5
(8 l"/o
(42%)
(21%)
(21%)
0"/o)
"Some patients presented with more than one clinical finding or
indication for ERCP
Table 4 Time from surgery to ERCP, days (n 52)
Median Range
Group 19.0 3-337
Group 2 7.5 1-354
Group 3 118.0" 7-227
Overall 21.0 1-354
aP =.0005, Kruskal-Wallis
0.8 mg/dl (0.1-9.0) (Table 3). The median delay between
surgery and ERCP was 21 days(range, 1-354) (Table4).
Group 1.
Nineteen patients were diagnosed with bile duct injury or
bile duct leak by ERCP. The median time from surgery
until ERCPwas 19 days (range, 3-337) (Table4). Abnormal
liver chemistries were present in 15 (79%): median (range)
AST 36 u/1 (5-265),ALT 46 u/1 (1-440),AP 162 u/1 (52-
678),TB 1.4 mg/dl (0.3-6.0). Cholestasis withoutjaundice
was the most frequent finding with elevations of AP in
67%. Transaminases were mildly elevated (1.5X normal)in
40% ofpatients. Ten patients (52.6%) had an abdominal
fluid collection (biloma) requiring CT-guided drainage.
Five patients (26%) had attempted repair ofthe injured site
or biliary-enteric bypass acutely and were referred for
ERCP with suspected complication.
The cystic duct (CD) stump was the most common site
ofbile leak (n 9) (Table 5). Adisrupted CBD (n 1), CBD
Table5 Injury site, N
LEAK
Cystic duct
Common bile duct
Right hepatic duct"
STRICTURE
Common bile duct, complete 2
Common bile duct, partial 2
Common hepatic duct 3
patient diagnosed and treated at ERCP; patient failed
diagnostic ERCP and was treated precutaneously
ERCP AFTER LAPAROSCOPIC CHOLECYSTECTOMY 189
leak (n 1) and RHD leak (n 1) were identified. Com-
plete obstruction of the CBD was seen in 2 patients.
Strictures were identified, in the CBD in 2 patients and
CHD in 3 patients.
Endoscopic therapy was initiated in 12 patients (Table
6). Six cases ofbile duct injury or leak were treated with
endoscopic prosthesis (EP). Leaks from the CD stump
(n 5) and RHD (n 1) were stented for a median duration
of37 days. Three patientswith strictures ofthe CBD (n 2)
and CHD (n 1) underwent a trial of EP for a median
duration of96 days. EP was successful in 5 of6 leaks (83%)
and 2 of 3 strictures (67%). Three of3 leaks (100%) were
successfully treated by ES alone. Two patients underwent
endoscopic sphincterotomy (ES) for concomitant stone
extraction. ES was not required for stent placement.
Surgical correction was performed as primary therapy
in 6 patients: hepato-jejunostomy was performed forcom-
plete CBD obstruction (n 2), CHD stricture (n 2), and
disrupted CBD (n 1); patient with a leak of the CD
stump underwent surgical repair.
Diagnostic ERCP failed in one patient who presented
with a biloma; a RHD leak was indentified by per-
cutaneous cholangiogram and the patient underwent
hepato-jejunostomy. Access for therapeutic ERCP failed
in one patient who presented with a dislodged tube which
had been placed in the CBD at surgery. At that time,
complete transection of the CBD was recognized and
immediate choledochoduodenostomy was performed.
The patient was successfully treated with a percutaneously
placed stent. EP failed in the patient with the RHD leak
who underwent subsequent Longmire procedure. EP
(total duration, 300 days)failed in one CBD stricturewhich
occurred after primary repair of a transected duct. This
patient underwent successful hepato-jejunostomy.
Overall, definitive therapywas provided by EP in 7 of9
patients (78%) and ES in 3 of 3 patients (100%). Overall
Table 6 Summary of ERCP results (n 52)
Success Failure Complications
Diagnostic
Group 6 0
Group 2 4 0 0
Group 3 13 2
Total 23 (92%) 2 (8%) 2
Therapeutic
Group 10 2 0
Leak (EP) 5 0
(ES) 3 0 0
Stricture (EP) 2 0
Group 2 14 0
Group 3
Total 24 (92%) 2 (8%)
Mild pancreatitis
Access for therapy failed in patient
success for attempted therapy in this group was 83%
(Table6).
Group2.
Eighteen patients were suspected to have retained bile
duct stones causing abnormal liver chemistries, abdominal
pain, or an abnormal cholangiogram. Abnormal liver che-
mistries were present in 12 (67%): median (range) AST 61
u/k (12-400), ALT 75 u/1 (7- 428), AP 172 u/1 (55-575), and
TB 2.2 mg/dl (0.2-9.0). Cholestasis withjaundice was most
common, with elevations ofalkaline phosphatase and bili-
rubin in >60% ofpatients. Nine patients had suspected bile
duct stones on the basis ofan abnormal cholangiogram;
one ofthese was found to have a clear bile duct at the time
of ERCP. Retained stones were confirmed in an addi-
tional 6 patients. Three patients were found to have a clear
bile duct at the time ofERCP, however, the papilla appe-
ared "ragged", raising the suspicion that a stone had rece-
ntlypassed. A total of 14 patients were treated for retained
bile duct stones: 12 of 14 (86%) required ES;5/14 (36%)
required more than one procedure to clear the bile duct.
Overall success of therapy in this group of patients
was 100%.
Group3.
Fourteen patients were evaluated for asymptomatic eleva-
tions of liver chemistries (n=1) or post-LC pain (n= 13).
Abnormal liver chemistries were present in 4 (28.5%):
median (range) AST 37 u/1 (8-81), ALT 32 u/1 (11-112), AP
111 u/1 (55-391), TB 0.55 mg/dl (0.1-1.9). Diagnostic ERCP
failed in patient who could not tolerate the procedure.
Two patients had evidence for papillary stenosis with
delayed drainage of contrast from the bile duct; no
therapy was undertaken in one while one patient under-
went surgical sphincteroplasty. One patient had evidence
ofpancreatitis and normal bile ducts. The remaining 10
patients had normal bile ducts.
For this entire series, diagnostic procedures alone were
attempted in 25 patients; therapeutic procedures were
attempted in 27 cases. Diagnostic ERCP failed in 2
of 25 cases (8%). Access for therapy failed in of
27 cases (3.7%). Three complications occurred in this
series. Two patients evaluated for post-LC pain developed
Table 7 Summary ofResults
Success by intent Successfortherapy
Group 18/20(90%) 10/12(83%)
Group II 18/18(100%) 14/14(100%
Group III 13/14(92.8%)
Overall 49/52 (94.2%) 24/26 (92.3%)
190 C.M. SCHMITT et al.
500
400
300
200
100
III
Diagnostic Group*
*p .09 KruskaI-Wallis
500
400
300
200
0
III
Diagnostic Group*
*p ,07 Kruskal-Wallis
outlier
Third Quartile
Mean
Median
First Quarhle
700
600
"J 500
400
o
. 300
200
100
NSS
Diagnostic Group*
Diagnostic Group*
*p ,004 KruskaI-Wallis
Figure Liver chemistries by diagostic group.
mild pancreatitis. One patient who underwent ES and
stone extraction with interim stent placement developed
mild pancreatitis (Table 7).
Differences in liver chemistry abnormalities were
statistically significant between the 3 major diagnostic
groups.(Table 3 and Figure 1) The difference in delay time
between surgery and ERCP for the 3 major diagnostic
groups was very highly statistically significant,p .0005
(Figure 2).
DISCUSSION
In the absence of prospective, randomized trials, the en-
thusiasm for LC has been tempered by careful scrutiny of
associated complications. Appeals for circumspection in
the use ofthe procedure and credentialing oftrainees are
now familiar9-1. Attention is turning to the long-term
outcome and management ofcomplications after LC. The
therapeutic endoscopist can serve an important role in the
ERCP AFTER LAPAROSCOPIC CHOLECYSTECTOMY 191
400
E
oO
E o
300
200
100
II
Diagnostic Group*
*p .0005 KruskaI-Wallis
Figure 2 Time from surgery to ERCP (days).
management ofpost-operative dilemmas as described in
this case series.
Bile duct injury has emerged as the most serious
complication of LC and appears related to early
experience2,
6. The classic pattern ofinjury occurs when
the common bile duct is mistaken for the cystic duct and a
portion of the misidentified duct is then removed. The
major post-operative manifestations are bile leak and
biliary obstruction
The management strategy for injuries which are sus-
pected post-operatively will depend on the expertise
available. Adequate visualization ofthe leak site, percu-
taneous drainage of fluid collections, and relief of distal
obstruction are rules for successful management.Radi-
ologic and endoscopic management have the advantage of
avoiding further surgical morbidity.
Percutaneous transhepatic drainage provides defini-
tive management for biliary fistulae in 50-80/,, ofcases4
5.
This method may also temporize by diverting bile flow
away from the bile duct defect until the patient's clinical
condition improves for surgical repair. However, in addi-
tion to the risk ofbleeding due to transhepatic puncture,
percutaneous drainage may be mor.e difficult in this group
of patients since the bile ducts are effectively decom-
pressed. For these reasons, we reserve this approach for
patients who have failed endoscopic access.
Success rates exceeding 75% for ES and EP have been
demonstrated for management ofpost-operative biliary
fistulae 3. ,6. The endoscopic management ofsimilar sequ-
elae after LC appears to be increasing. Wootton reported
successful treatment of2 of3 cystic duct leaks treated with
EP'7. Kozarek et al., have reported the most complete
series to date. Three CD leaks, 6 CBD leaks, and 2 CBD
transections were identified at ERCP. Bile leaks sealed in
the 9 patients treated endoscopically. The discrete referral
base and consecutive nature ofthe patient sample allowed
better characterization ofthe range ofinjuries and man-
agement6. In our case series, we have demonstrated
successful treatment in 5 of6 patients (83%) with EP and 3
of3 patients (100%) with ES. The similar success rates for
ES and EP suggest an ana!egous mechanism: relief of
relative obstruction at the sphincter ofOddi.3
The retro-
spective nature and small number of cases limit valid
comparisons of the two approaches. ES has been reco-
mmended in this setting because ofinfection and blockage
associated with stents'8. We prefer EP over ES to avoid
the increased risk of bleeding, perforation, and pancre-
atitis associated with ES8. The limited duration ofstent
placement (median, 37 days) obviates the need for routine
stent exchange since these complications are unlikely to
occur. We do not routinely perform ES for placement of
the stent.
High success rates for endoscopic management of
post-operative biliary strictures has been similarly demon-
strated. Good to excellent results were shown by Davids,
et al. in 83% of patients treated with EP for one year,
however, restricturing occurred in 17% ,9. Accounts of
this modality for managing post-LC strictures are limited
to two reports. Weber treated a stricture related to a CD
clip with EP2. Wootton's series included 2 CBD stric-
tures; of these was successfully treated with EP'7. We
attempted therapy in 3 patients with strictures after LC
and achieved resolution in 2. Only long-term follow-up will
define the success ofthis therapy. The reasons for limited
endoscopic experience in this clinical setting are unclear.
We have not attempted to describe our referral base,
therefore the denominator and rate for this particular
injury is undefined in our series. The referral pattern for
complications ofthis relatively new surgery may be con-
fined to the surgical community2. Complete or compli-
cated obstruction will require expert surgical correction.
However, our results suggest that a trial of endoscopic
therapy is warranted in the appropriate clinical setting, as
for any benign bile duct stricture.
Are retained bile duct stones "complications"? This is a
matter ofsemantics. The endoscopic removal ofretained
192 C.M. SCHMITT et al.
stones is conventional; our success rate after LC is high
(100%). Currently, attention is appropriately focused on
pre-operative identification and management ofpatients
with suspected choledocholithiasis2-23.
Davidoff et al., emphasized that prolonged or severe
abdominal pain post-LC should heighten suspicion for a
complication, since one of the benefits of LC is relative
lack ofpost-operative discomfort.We observed a dist-
inct clinical presentation for the 3 majordiagnostic groups
based on timing of ERCP and degree of abnormal liver
chemistries, Patients with findings at ERCP of serious
consequence (bile leaks, strictures and retained stones)
underwent study within 1-2 weeks of surgery and liver
chemistries were more strikingly abnormal. In contrast,
patients in the group with post-LC pain had relatively
unremarkable elevations in liver chemistries and pre-
sented 3.9 months after surgery. A low threshold for study
is reflected in earlier referral for patients with objective
evidence of significant disease (e.g., presence of biloma,
abnormal cholangiogram, abnormal liver chemistries).
Our review was retrospective and the sample was drawn
from patients referred to a tertiary center for biliary endo-
scopy. We conclude that a low-threshold for diagnostic
evaluation of potential post-operative complications
should be maintained, especially in patients with abdo-
minal pain or abnormal liver chemistries. This case series
demonstrates that ERCP is ideally suited as an adjunct to
laparoscopic surgery to address both diagnosis and
therapy ofcomplications.
Outcomes research defining the nature and tong-term
significance of post-LC complications is required. The
prospect is both exciting and formidable. This series
demonstrates an excellent example of multidisciplinary
collaboration.
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