Selection Criteria for Preoperative Endoscopic Retrograde Cholangiopancreatography in the Laparoscopic Era

Background:  Indicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography.

Objective:  To refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP).

Design:  Retrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy.

Setting:  Two ERCP units in adjacent teaching hospitals.

Patients:  Three hundred seventeen patients with gallstones and in situ gallbladders.

Intervention:  Common bile duct imaging at ERCP.

Main Outcome Measures:  Abnormalities justifying ERCP.

Results:  Abnormalities justifying ERCP were found in 66% of patients. This group differed significantly from those with normal ducts, with more being referred with abnormal results of all liver function tests (P<.001), jaundice (P<=.001 ), a dilated CBD on ultrasound (P<.001), or CBD stones on ultrasound (P<.001), On the other hand, patients with normal ducts were significantly more likely to have been referred with pancreatitis (P=.003) or elevated results of individual liver function tests (P<.001). A logistic regression model using age, presence of jaundice at ERCP, levels of alkaline phosphatase and albumin, and ultrasonography showing dilated ducts or visible CBD stones was found to have a specificity of 75% and a sensitivity of 89%. Past pancreatitis or elevated results of individual liver function tests were not predictive factors.

Conclusion:  The use of such a model rather than individual criteria would improve the selection of patients for preoperative ERCP, optimizing its role in the laparoscopic era.(Arch Surg. 1996;131:89-94)