With the advent and widespread dissemination of laparoscopic cholecystectomy, endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy were united, as if in an arranged marriage: the relatives (practitioners) on both sides were enthusiastic, but the technologies themselves were tentative and uncertain about their respective roles in specific situations. Like the wedding dance, there was potential for excess: feet were trod upon, and there was the technical equivalent of elaborate twirls and dips that did little to cement a long-term bond. How else to explain the rush to do preoperative ERCP at the slightest hint of a common bile duct stone (mild pancreatitis, minimal bile duct dilation on ultrasound, minor transaminase elevations)? It is no wonder that the marriage partners became mistrustful or, at least, looked askance at each other. Not only were up to three quarters of ERCPs unnecessary, but there was also a subset of patients who sustained a procedural complication. 1–3 So, even as one partner learned to limit its excesses (preoperative ERCP, in the author's opinion, should be considered for cholangitis, severe biliary pancreatitis, obstructive jaundice, and documented common bile duct stones [e.g., documented by ultrasonography, endoscopic ultrasonography, magnetic resonance cholangiopancreatography, intravenous cholangiogram] in high surgical risk patients), 4–9 both began the inevitable finger pointing that brings further discord to any significant relationship: I would not be performing so many ERCPs if you could perform routine intraoperative cholangiography and remove common bile duct stones laparoscopically. 10,11 And besides, you are operating on too many people (given the 10% increase in gallbladder removal annually since the introduction of laparoscopic cholecystectomy). On the flip side, if I could be certain that you would be successful in removing a common bile duct stone found during laparoscopic cholecystectomy, it wouldn't be necessary to perform so many preoperative ERCPs, to open the patient, or to develop a time-consuming and technically demanding skill.
And so, with the accusations and countercharges shuttle-cocking between the partners, this technical marriage has lurched to a comfortable and institutionally dependent compromise: take a little bit up front preoperatively, if you must, but be there for me postoperatively if I need you, 2,8,11 which brings me to the series by Contractor et al. 12 in the current issue of the Journal. To begin with, the authors got it right: the bulk of ERCP–laparoscopic cholecystectomy interaction today should be in the postoperative setting. The postoperative setting assures the necessity of the procedure by virtue of symptoms, abnormal imaging (46 of 62 [76%] cases in the Contractor et al. series), or persistent laboratory abnormalities. This approach will avoid unnecessary procedures in individuals with minor postoperative biliary leaks or those with tiny bile duct calculi, most of which have been shown to pass spontaneously without complications. This approach also saves money and minimizes complications but places a rather large onus on the endoscopist to be successful procedurally. In fact, we have previously reported that 92% of ERCP–laparoscopic cholecystectomy interaction in our institution occurred in the postoperative setting. 13 Endoscopic findings included bile duct stones (31%), ductal leak and/or stricture (26%), cystic duct leak (6%), and papillary stenosis/microlithiasis (19%). Eleven percent of patients were studied for postoperative pancreatitis, two thirds of whom were found to have biliary gravel and one third of whom were thought to have passed stones. These patients were all successfully diagnosed and/or treated, and only 7% of patients who were studied postoperatively were thought to have a normal exam. The series by Contractor et al. reinforces these findings, as 46 of 62 (74%) patients underwent successful endoscopic therapy for stones, stenoses, or bile leaks, and an additional 4 patients were sent to surgery for a bile duct transection.
Both series 12,13 reinforce the need for a relationship, if not a technologic marriage. Despite differences in culture, skill sets, and timing of the interaction, ERCP and laparoscopic cholecystectomy will maintain an intimacy that will vary from institution to institution. A mutual respect has developed, and these complementary and competitive technologies might even learn to love one another—if only for the children's (patients') sake.
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