VALUE OF ERCP IN DIAGNOSIS AND MANAGEMENT OF COMPLICATIONS OF LAPAROSCOPIC CHOLECYSTECTOMY

Biliary complications are more frequent in laparoscopic than in open cholecystectomy. The aim of the study was to evaluate the diagnostic and therapeutic value of endoscopic retrograde cholangiopancreatography (ERCP) in the management of complications of laparoscopic cholecystectomy. We therefore report on the result of 49 ERCP after laparoscopic cholecystectomy done at our department between January 1991 and March 1993. Patients were referred from 16 different surgical institutions. In 29 cases endoscopic sphincterotomy was performed without complications. Indications for ERCP were ''persistent biliary pain'' (n = 27), bile leakage (n = 7), pancreatitis (n = 5), abscess (n = 5), painless jaundice (n = 3) and asymptomatic bile duct stone in routine cholangiography (n = 2). In the group of patients with ''persistent biliary pain'' we found bile duct stones in 12 (80%) of 15 cases with cholestasis and in 3 (30%) of 10 without cholestasis. The stones were endoscopically removed after sphincterotomy. In 2 patients without cholestasis, cannulation of the bile duct failed. 7 patients showed biliary leakage, 4 from inadequate clipping of the cystic stump (2 in combination with a common bile duct stone), 2 from the hepatic duct and 1 from insufficient anastomosis after reconstruction of a common bile duct. After endoscopic sphincterotomy and, if necessary, stone extraction by Dormia basket, leakage from the cystic stump and hepatic duct healed. The insufficient common bile duct anastomosis required reconstruction by hepaticojejunostomy. Three of 5 patients with postoperative pancreatitis had common bile duct stones, while one with chronic pancreatitis had a concrement in the pancreatic duct which was endoscopically removed. In none of the 5 patients with postoperative abscess (2 subhepatic, 2 intrahepatic, 1 retroperitoneal) did ERCP show a leakage. In the 3 patients with painless jaundice, one had total occlusion of the common bile duct by a clip, one stenosis because of thermic laceration by electrocauter, and one had a stricture after common bile duct anastomosis which was dilated transhepatically by Gruntzig balloon catheter after passage of the guidewire failed by transpapillar route. We conclude that ERCP with, if necessary, sphincterotomy is of great diagnostic and therapeutic value in the management of complications of laparoscopic cholecystectomy. Patients with persistent ''biliary pain'' after operation require ERCP even when there are no signs of cholestasis in laboratory or ultrasound.