Single Anesthesia ERCP and Laparoscopic Cholecystectomy for Management of Common Bile Duct Stones

Abstract

Management of choledocho-cholelithiasis requires a multi-disciplinary approach. It involves clearance of common bile duct stones (CBDS) on the one hand and addressing gallstone disease (GSD) on the other hand. With technological advancements and growing expertise in the fields of endoscopy and laparoscopy, endoscopic retrograde (or radiological) cholangiopancreatography (ERCP) and laparoscopy cholecystectomy (LC) have become modalities of choice for CBDS and GSD, respectively. Conventionally, in patients with choledocho-cholelithiasis, ERCP is performed first followed by LC after an interval of 4–6 weeks. This approach requires two separate admissions involving anesthesia twice, thus increasing the risk related to multiple general anesthesia, higher cost of care, and greater loss of man hours. These issues can be mitigated by the novel approach of single anesthesia ERCP and laparoscopic cholecystectomy (SERLAC). At our center, we follow both approaches, depending on the availability of resources and patient characteristics. This study aims to evaluate the safety of SERLAC. In this retrospective, descriptive study, we analyzed data of patients undergoing SERLAC for outcome, complications, benefits, and constraints. Of the 36 patients who underwent ERCP before LC for choledocho-cholelithiasis, 10 opted for SERLAC. Despite relatively prolonged anesthesia time (mean 85.3 min), owing to both ERCP and LC being performed in the same sitting, no anesthesia-related adverse event was noted. SERLAC was preferred in two cases to avoid exposure to second general anesthesia due to comorbidities such as old age with polytrauma and use of oral anticoagulant related to a prosthetic cardiac valve. Hospital stay was significantly lower (mean 4.3 days) in patients opting for SERLAC and it provided a definite cure for 8 out of 10 patients. The major constraint noted was logistical, in terms of ensuring the availability of the operating room (OR) and teams for both procedures besides setting up the ERCP and laparoscopy workstations in the same OR in quick succession. Our study shows that SERLAC is a safe approach and further studies are required to build consensus. This study has proven that SERLAC is safe and comparable to interval ERCP and LC. It offers a definite cure with a single admission, single anaesthesia, and significantly shorter hospital stay and thus results in much greater patient satisfaction in expert hands.