Selection criteria for preoperative endoscopic retrograde cholangiopancreatography in the laparoscopic era.
Robertson GS., Jagger C., Johnson PR., Rathbone BJ., Wicks AC., Lloyd DM., Veitch PS.
BackgroundIndicators for cholangiography were originally designed to select patients at risk for common bile duct (CBD) stones for intraoperative cholangiography.ObjectiveTo refine these criteria to apply to the much more invasive procedure of preoperative endoscopic retrograde cholangiopancreatography (ERCP).DesignRetrospective review of selection criteria for ERCP in consecutive patients referred over 18 months following the introduction of laparoscopic cholecystectomy.SettingTwo ERCP units in adjacent teaching hospitals.PatientsThree hundred seventeen patients with gallstones and in situ gallbladders.InterventionCommon bile duct imaging at ERCP.Main outcome measuresAbnormalities justifying ERCP.ResultsAbnormalities 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.ConclusionThe 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.