28 - ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY FINDINGS PROVIDE FURTHER JUSTIFICATION FOR A "SURGERY FIRST" MINDSET IN CHOLEDOCHOLITHIASIS

Objectives: Using endoscopic retrograde cholangiopancreatography (ERCP) initially for choledocholithiasis management creates a two-procedure pathway of ERCP followed by laparoscopic cholecystectomy (LC). In contrast, a single-stage, “surgery first”, approach consisting of LC with cholangiogram and possible laparoscopic common bile duct exploration (LCBDE) has a shorter length of stay with an equivalent safety profile. Despite this, nationwide referral patterns heavily favor ERCP first. The result is an undescribed proportion of patients undergoing ERCP prior to LC with CBD obstructions likely amenable to clearance via LCBDE. Preoperative ERCPs were reviewed in patients with a non-complicated presentation of choledocholithiasis to determine what proportion of patients may benefit from a surgery first approach that will decrease the instances in which patients are unnecessarily exposed to two separate anesthetic events.

Methods: We retrospectively reviewed 71 patients over the age of 18 who underwent ERCP first at a single center. Thirteen patients were excluded because of missing data, a diagnosis of cholangitis, or due to poor surgical candidacy. Endoscopic information collected and analyzed included ERCP indications, presence of stones and/or sludge, imaging, and stone size and number. Based on accepted criteria, stone size was categorized as small (0-4 mm), medium (5-7 mm), and large (≥8 mm).

Results: At the time of ERCP, 11(19%) patients had sludge only, 15 (26%) had sludge and stones, while 32 (55%) had stones only. Of those 47 with stones, 17 (36%) were small, 16 (34%) were medium, and 14 (30%) were large. Twenty-six patients (45%) had isolated choledocholithiasis, making it the most common primary indication for ERCP. This was followed by 25 (43%) with concomitant cholelithiasis and/or cholecystitis, gallstone pancreatitis 7 (12%). The diagnosis was suggested on ultrasound in 38 patients (65%), CT scan in 36 patients (63%), and MRCP in 23 patients (40%), with 21 (36%) undergoing multiple imaging modalities that included MRCP. Of all patients who underwent ERCP, 76% of patients had findings of sludge and/or stones that might have been amenable to basic LCBDE maneuvers and would have benefited from a surgery first approach.

Conclusion: Our findings suggest that the majority of patients who underwent preoperative ERCP for suspected choledocholithiasis had obstructions that are amenable to LCBDE. Implementing surgery first management for suspected choledocholithiasis can offer an efficient alternative to the more common pathway of ERCP followed by LC. Renewed efforts are needed to promote LCBDE implementation and disseminate effective training to general surgeons.