Predicting the degree of difficulty of laparoscopic cholecystectomy following endoscopic retrograde cholangiopancreatography- Subgroup analysis does not improve the prediction.

Dear Sir,

In our practice, we have observed a higher conversion rate (8%) in patients undergoing laparoscopic cholecystectomy (LC) following endoscopic retrograde cholangiopancreatography (ERCP). Similar findings have been reported in the literature. It remains to be confirmed whether this higher degree of operative difficulty is due to ERCP itself or is secondary to co-existing gallstone pathologies, namely acute cholecystitis (AC) and pancreatitis. We set out to establish if the indications for ERCP, ERCP-related factors (number of ERCPs, sphincterotomy, stone retrieval, stent insertion and time between ERCP and LC) and co-existing gallstone pathologies would affect the degree of difficulty (DoD) of LC following ERCP.

We conducted a retrospective cohort study of patients who had pre-operative ERCP for choledocholithiasis and subsequent LC at our UK tertiary centre between January 2016 and November 2017. Indication for ERCP (cholangitis, obstructive jaundice [OJ] and incidental common bile duct [CBD] stone), timing and components of ERCP, co-existing gallstone pathologies (AC and pancreatitis), peak white blood cell (WBC) count and peak C-reactive protein (CRP) during index admission were studied. Diagnosis of OJ, cholangitis, AC and pancreatitis was based on the Tokyo Guidelines and the Atlanta criteria. DoD of LC (Levels 1–4, 4 = most difficult) was defined using the Nassar classification.

A total of 111 patients were included (57.6% female; age 22–83, mean 58 years). The presenting pathologies were cholangitis (39.6%), OJ (30.6%), incidental CBD stone (1.8%), AC with CBD stones (15.3%) and pancreatitis with CBD stones (12.6%). Patients had between 1 and 3 ERCPs (one = 82%, two = 15.3% and three = 2.7%). Sphincterotomy, stone retrieval and CBD stent were performed in 92.8%, 82.9% and 22.5%, respectively. Of the 111 cholecystectomies (17.1% emergencies), 91% were laparoscopic and 9% were converted to open to allow safe completion. The distribution of operative DoD was Level 1 (25.2%), Level 2 (21.6%), Level 3 (34.2%) and Level 4 (18.9%).

We found no association between DoD with age, gender, number/components of ERCP, time between ERCP and LC, WBC and CRP.

Amongst the indications for LC, AC was associated with higher DoD (Spearman's rs= 0.24, P = 0.013). Most LCs performed in AC patients are DoD Levels 3–4 (76.5%), whereas most performed in pancreatitis patients are Levels 1–2 (71.4%). Although not achieving statistical significance, they are in line with findings from our previous studies on LC that DoD was lower amongst pancreatitis patients and DoD was higher in AC patients with high CRP.[12] The small population and retrospective nature are limitations of our study.

In summary, there is no single factor related to ERCP that would make LC more difficult. A study of 157 patients by Cinar et al. also reported that ERCP timing, stone retrieval and CBD stent did not affect conversion.[3] It appears that inflammatory gall bladder pathology (i.e., cholecystitis), rather than ductal pathologies, is the determining factor of operative DoD. We believe that further subgroup analysis of ERCP cohort is unlikely to have any clinical impact on predicting DoD and conversion.

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Conflicts of interest

There are no conflicts of interest.