What features on intraoperative cholangiogram predict endoscopic retrograde cholangiopancreatography outcome in patients post cholecystectomy?

Background: Endoscopic retrograde cholangiopancreatography (ERCP) is a procedure performed to remove bile duct stones. Intraoperative cholangiography (IOC) is often performed at the time of cholecystectomy to determine the presence of intraductal stones. However, many of the ERCP procedures performed for this indication fail to find any intraductal stones. Given that ERCP carries significant patient morbidity, we investigated whether there are features on IOC that can guide ERCP patient selection.

Methods: A retrospective analysis of 152 patients who had an IOC filing defect and a subsequent ERCP was performed.

Results: Small single stones greater than or equal to 4.5 mm on IOC can be used to predict the presence of stones on a subsequent ERCP. Furthermore, ERCPs performed for single filling defects smaller than 4.5 mm are more likely to be negative if performed later rather than earlier, suggesting that small stones can pass over time. We show that 80% of these stones will pass by 11 days after the IOC.

Conclusion: Single small stones on IOC should be given adequate time to pass into the intestine. Imaging should be performed to determine if the stone has passed into the intestine after day 11 prior to performing a therapeutic ERCP.