Cholecystolithiasis complicated with choledocholithiasis is a common clinical situation. Several guidelines recommend that patients diagnosed with CBDSs be offered stone extraction, if possible (3, 18). LCBDE and LC plus intra-operative ERCP are both excellent strategies. However, they are not easily accessible in all centers. Thus, pre-operative ERCP plus LC is a commonly used approach. However, pre-operative ERCP can make cholecystectomy difficult due to bacterial colonization in the bile ducts resulting in infection of the hepatoduodenal ligament (19), and hence high-grade adhesions in the gallbladder triangle (16). Many clinicians have explored the ideal interval time from ERCP to LC, as shown in Table 6, but this is still controversial to date. Based on data shown in Table 6, this approach is safe because only two deaths have been reported so far and the complication rate is not high. The conversion rate to open surgery varies from 0% to 25% in various studies. Some studies have suggested that performing LC within three days post-ERCP is a better option because of fewer complications, shorter operative time, and shorter hospitalization. Aziret et al., and Gao et al. reported that performing LC within one to three days of ERCP was associated with a lower complication rate as compared with LC done four days or later. They also found that performing LC within one to three days of ERCP shortened the operative time (7, 11). Borreca et al., Wild et al., and Trejo-Avila et al. suggested performing LC within 24 h post-ERCP so that hospitalization could be significantly shortened (10, 13, 15).

LC is a gold standard operation for gallstones with or without acute cholecystitis, even with severe inflammation. We enrolled patients with acute cholecystitis, acute cholangitis, and mild biliary pancreatitis and had satisfactory outcomes. Our study did not find any difference in the conversion rate to open surgery or major operative complications among the three groups. The overall conversion rate and LC-related complications were both 1.4%. These were relatively low and consistent with the results of a study by Borreca et al. (15). As reported by Aziret et al. and Gao et al., operative time was significantly longer in patients receiving LC four days or later after ERCP (7, 11). These results indicate that LC should be done within three days after ERCP. We believe inflammation and adhesion around the gallbladder triangle caused by ERCP and by cholecystitis itself are similar. Early LC (performed within 1–3 days) has been recommended for acute cholecystitis to improve patient outcomes including fewer complications, shorter hospital stay, and hospitalization costs (20).

We found in our study that patients with biliary pancreatitis, calculus in the neck of the gallbladder, and gallbladder wall thickness ≥4 mm before ERCP had longer operative times, indicating that ERCP is not the only factor responsible for prolonged operative time. Extensive inflammation caused by gallstones, CBDSs, and bacteria in the bile can also make LC very difficult (17). Surgeons operating on patients with gallstones and co-existing CBDSs should be mindful of the fact that factors other than ERCP may contribute to difficulties during surgery, and should consider switching to open surgery if needed to reduce postoperative complications or delay surgery till inflammation subsides.

Length of hospital stay is an important standard because longer hospital stays mean higher hospitalization costs (15). Post-cholecystectomy hospital stay was similar among three groups, while post-ERCP hospital stay was significantly longer in group 3. These results indicated that early LC does not prolong post-cholecystectomy hospital stay. The time taken for waiting for LC after ERCP significantly prolongs the length of hospital stay after ERCP, and such a wait is probably unnecessary.

Based on our study and studies published previously, performing LC in the same admission as ERCP is safe and effective, even though these patients may have underlying acute cholecystitis, acute cholangitis, or mild biliary pancreatitis. Further, recurrent biliary symptoms and biliary complications including gallbladder perforation and recurrent choledocholithiasis can be reduced (12). Performing LC early within three days rather than four days or later after ERCP is recommended because of the reduced operating time and hospital stay, without increased complications and conversion rates. In patients with risk factors for difficult surgery, especially those with a high possibility of conversion to open cholecystectomy, attention is needed during surgery to reduce biliary injury. Percutaneous transhepatic gallbladder puncture drainage may have to be considered in some patients to overcome severe acute inflammation, prior to a second surgery (21).

The limitation of our study is that it was a single center retrospective study. The limitations of retrospective analysis are inevitable. A large, multicenter, randomized controlled trial is needed to address whether LC done within three days of ERCP is superior in terms of fewer post-cholecystectomy complications and shorter hospital stay as compared with LC done four days or later after ERCP.

In conclusion, LC performed within three days after ERCP is safe for patients with gallstone coexisting CBD stones, even in the presence of acute cholecystitis, acute cholangitis, and mild biliary pancreatitis, and is associated with fewer post-cholecystectomy complications and shorter hospital stay.