Selection criteria for preoperative endoscopic retrograde cholangiopancreatography in the laparoscopic era
G. S. Robertson, C. Jagger, P. R. Johnson, B. J. Rathbone, A. C. Wicks, D. M. Lloyd and P. S. Veitch
Department of Surgery, Leicester Royal Infirmary, England.
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.
