Study finds three or more preoperative ERCP procedures and multiple biliary stents are associated with a higher likelihood of laparoscopic subtotal cholecystectomy
Previous endoscopic retrograde cholangiopancreatography (ERCP) may be associated with greater operative difficulty during subsequent laparoscopic cholecystectomy (LC), according to a recent study published in BMC Surgery.
Researchers found that the likelihood of requiring laparoscopic subtotal cholecystectomy (LSC) increased among patients who had undergone repeated ERCP procedures before surgery. Three or more preoperative ERCP interventions were particularly strongly associated with the need for subtotal cholecystectomy.
The findings suggest that the cumulative burden of ERCP, including repeated procedures and multiple biliary stent placements, may contribute to increased surgical complexity during subsequent gallbladder removal.
Study Evaluated 426 Patients Undergoing Laparoscopic Cholecystectomy
Researchers retrospectively assessed 426 patients who underwent laparoscopic cholecystectomy. Patients were divided according to whether they had previously undergone ERCP.
To reduce potential differences between the groups, the researchers performed 1:1 propensity score matching, adjusting for factors including age, sex, and American Society of Anesthesiologists (ASA) physical status.
The perioperative outcomes of matched patients were then compared to assess the association between previous ERCP exposure and surgical outcomes.
Researchers also conducted subgroup analyses within the ERCP-exposed group based on the indication for ERCP, interval between ERCP and LC, number of ERCP procedures, difficulty of stone extraction, and biliary stent placement.
Previous ERCP Associated With Greater Need for Subtotal Cholecystectomy
Following propensity score matching, patients with previous ERCP exposure had a significantly higher likelihood of requiring laparoscopic subtotal cholecystectomy compared with matched patients without previous ERCP exposure.
The difference in LSC rates between the groups was statistically significant (P = 0.003).
However, the rate of conversion from laparoscopic to open cholecystectomy did not differ significantly between the two groups (P = 0.996).
These findings indicate that previous ERCP may be associated with operative difficulty that can lead surgeons to use subtotal cholecystectomy as a surgical strategy, without necessarily increasing the likelihood of conversion to open surgery.
Three or More ERCP Procedures Linked to Higher LSC Risk
The number of previous ERCP procedures appeared to be an important factor.
Among patients who had undergone ERCP, those with three or more preoperative ERCP procedures had a significantly higher incidence of laparoscopic subtotal cholecystectomy (P = 0.004).
Multivariate regression analysis further demonstrated a strong association between three or more preoperative ERCP procedures and LSC. The adjusted odds ratio was 15.98 (95% CI, 2.70–94.39; P = 0.002), even after controlling for potential confounding factors.
Sensitivity analysis using fewer covariates also showed a significant association between multiple ERCP interventions and the need for LSC.
Multiple Biliary Stents Also Associated With LSC
The study found that biliary stent burden was another factor associated with surgical complexity.
Placement of two or more biliary stents was significantly associated with increased rates of laparoscopic subtotal cholecystectomy (P = 0.008).
Researchers also found that repeated stone extraction during ERCP was associated with a significantly longer total laparoscopic operative time.
These findings suggest that the cumulative nature of preoperative endoscopic intervention may be relevant when anticipating the technical difficulty of subsequent gallbladder surgery.
Findings Highlight Cumulative ERCP Burden
The researchers suggest that repeated ERCP procedures may contribute to inflammatory or fibrotic changes around the biliary tract, potentially making subsequent surgical dissection more challenging.
However, the study demonstrates an association rather than proving that repeated ERCP itself directly causes increased surgical difficulty.
The findings may nevertheless help surgeons consider a patient’s previous ERCP history, number of interventions, and biliary stent burden when planning laparoscopic cholecystectomy.
Clinical Implications
The study highlights the importance of carefully considering the timing and necessity of repeated endoscopic interventions in patients who may subsequently require cholecystectomy.
Patients who have undergone multiple ERCP procedures or received several biliary stents may require particular attention during preoperative planning because of the increased likelihood of a difficult operation and the potential need for subtotal cholecystectomy.
Further prospective studies will be needed to determine whether reducing repeated ERCP exposure or optimizing the timing between ERCP and cholecystectomy can alter surgical outcomes.
Important Highlights
- Previous ERCP exposure was associated with a greater likelihood of laparoscopic subtotal cholecystectomy during subsequent gallbladder surgery.
- The study retrospectively evaluated 426 patients undergoing laparoscopic cholecystectomy.
- Patients who underwent three or more preoperative ERCP procedures had a significantly higher incidence of LSC.
- Three or more ERCP procedures were associated with an adjusted OR of 15.98 for LSC (95% CI, 2.70–94.39; P = 0.002).
- Placement of two or more biliary stents was also associated with increased LSC rates.
- Multiple stone extractions during ERCP were associated with longer laparoscopic operative time.
