This study aimed to establish the optimal timing between endoscopic retrograde cholangiopancreatography (ERCP) and laparoscopic cholecystectomy (LC) for patients with common bile duct stones. Sixty patients were randomized into three groups based on the interval between ERCP and LC: short (≤3 days), medium (4-60 days), or long (≥60 days). The study found fewer intraoperative adhesions and shorter operative time and hospital stay in the short interval group. While conversion rates and complications did not differ significantly between groups, the results suggest an interval of within 72 hours between ERCP and LC may be preferable to allow for less adhesions and quicker recovery. Further larger studies

1. ‫البقرة‬ ‫سورة‬
)32(
‫العظيم‬ ‫ا‬ ‫صدق‬
‫م‬َ ‫ل‬ْ‫َم‬ ‫ع‬ِ‫ل‬ ‫ل‬ ‫ك‬َ ‫ن‬َ ‫حنا‬َ ‫ب‬ْ‫َم‬ ‫س‬ُ‫ب‬ ‫لوا‬ُ‫ب‬ ‫قنا‬َ
‫ك‬َ ‫ن‬َّ‫ك‬ ‫إ‬ِ‫ل‬ ‫ننا‬َ ‫ت‬َ ‫م‬ْ‫َم‬ ‫ل‬َّ‫ك‬ ‫ع‬َ ‫منا‬َ ‫ل‬َّ‫ك‬ ‫إ‬ِ‫ل‬ ‫ننا‬َ ‫ل‬َ
‫م‬ُ‫ب‬ ‫كي‬ِ‫ل‬ ‫ح‬َ ‫ل‬ْ‫َم‬ ‫ا‬ ‫م‬ُ‫ب‬ ‫لي‬ِ‫ل‬ ‫ع‬َ ‫ل‬ْ‫َم‬ ‫ا‬ ‫ت‬َ ‫ن‬ْ‫َم‬ ‫أ‬َ

2. Proper Timing of Elective Laparoscopic
Cholecystectomy After Endoscopic
Retrograde Cholangiopancreatography
With Sphincterotomy: A Prospective
Observational Study
By
Tamer Rushdy Hosseini
Assistant Lecturer of General SurgeryAssistant Lecturer of General Surgery
Faculty of Medicine - Zagazig UniversityFaculty of Medicine - Zagazig University

4. First of all, my thankful toFirst of all, my thankful to ALLAH,ALLAH, whowho
gave me the strength to finish thisgave me the strength to finish this
workwork..
My greatest sincere gratitude and deep
appreciation to Hemeida Elsayed
Mohammed, Professor of General Surgery,
Faculty of Medicine, Zagazig University, for
being highly caring, helpful and supportive
for me. His paternal advices were kindly
given to me that helped to bring this work
into light.

5. Words fail to express my sincere
gratitude to Abdel-Rahman Hassan
Sadek, Professor and Head of
General Surgery Department,
Faculty of Medicine, Zagazig
University, who scarified a great
deal of his valuable time and
experience to guide me throughout
the whole work.

6. Last but not least, I wish to express
my sincere appreciation to
Prof. Dr Samir Ibrahim Mohammed,
Professor of General Surgery,
Faculty of Medicine, Zagazig
university, for his continuous effort
and energetic help without which
this work would have never been
completed.

8. Common bile duct stonesCommon bile duct stones
occurs in 10-15% of patients withoccurs in 10-15% of patients with
symptomatic gallstone disease.symptomatic gallstone disease.
In general, common bile ductIn general, common bile duct
stones should be removedstones should be removed
because they may be associatedbecause they may be associated
with complications such aswith complications such as
gallstone pancreatitis andgallstone pancreatitis and
cholangitischolangitis

9. There is at present no consensus on
the ideal management of common bile duct
stones
ERCP then laparoscopic
cholecystectomy versus single-stage
laparoscopy,
postoperative endoscopic retrograde
cholangio-pancreatography versus
laparoscopic choledochotomy,
preoperative versus postoperative
endoscopic retrograde cholangio-
pancreatography .

10. An accepted treatment strategy for
cholelithiasis with secondary
choledocholithiasis is the laparoscopic
cholecystectomy following endoscopic
retrograde cholangiopancreatography.
Although early cholecystectomy is
advised, there is no consensus about the
time interval between laparoscopic
cholecystectomy and endoscopic
retrograde cholangiopancreatography

11. We do not know enough about the
effects of:
the time elapsed between ERCP and
laparoscopic cholecystectomy on
operation and operation outcomes .

12. Intraoperative and postoperative
complications and conversion to open
surgery have been reported to be more
frequent in patients who undergo ERCP
prior to laparoscopic cholecystectomy.
However, the mechanisms underlying this
pattern have not been identified

14. The aim of this work was to
establish the feasibility,
complications and outcome of
different time intervals between
endoscopic retrograde
cholangiopancreatography and
laparoscopic cholecystectomy in
management of common bile duct
stones.

16. This study was carried out on 60
patients who were randomized by
systematic randomization into three
equal groups according to the
interval between endoscopic
retrograde cholangiopancreato-
graphy and laparoscopic chole-
cystectomy defined as short (3days
or less), medium (4–60days) or long
(60 days or more)

17. All patients have undergone
endoscopic retrograde cholangio-
pancreatography with sphincterotomy
followed by elective laparoscopic
cholecystectomy

18. Inclusion criteria:
Patients who had been admitted to our
department for cholelithiasis were evaluated
for the risk of CBDS. The indications for ERCP
were one or more of the following: elevated
serum bilirubin level ,elevated alkaline
phosphatase,GGT,dilated common bile duct
(≥8 mm) and/or stones in common bile duct at
ultrasonographic (US) examination

19. Exclusion criteria:
The patients who has complications related to
endoscopic retrograde cholangiopancreatography
was excluded from our study
Patients with findings of acute cholecystitis,
pancreatitis, cholangitis and patients with contrast
agent allergies or known inflammatory disease was
excluded from the study, as inflammation can
interfere with the study.
Patients with previous upper abdominal operation,
history of peritonitis or history of endoscopic
retrograde cholangiopancreatography will be
excluded from the study because of
intraabdominal adhesions risk .

20. Investigations:
1- Laboratory:-
A- Routine laboratory investigations:--
1.Urine analysis
2. Complete blood count.
3. Fasting blood sugar.
4. Urea and creatinine in serum.
5. Liver function tests (total bilirubin,
direct bilirubin, total protein, AST,
ALT, ALP, GGT and prothrombin
time).
B- Specific laboratory investigations: - e.g.
Lipase, amylase.

21. 2- Imaging studies:-
A- Transabdominal ultrasonogrphy:-
It was done for all patients using .We
looked at, gall bladder stones, signs of
acute or chronic cholecystitis, (CBD)
dilatation or stones. Also, we looked at the
liver for diseases as cirrhosis, fibrosis,
dilated intrahepatic radicals.

22. B- Magnetic resonance cholangiopancreatico
raphv (MRCP) :
It was used in patients with positive history
suggestive of biliary stone disease and
ultrasonography did not reveal stones in a
dilated CBD.

23. The operative interventions :
All patients were managed by endoscopic
retrograde cholangio-pancreatography with
sphincterotomy followed by elective
laparoscopic cholecystectomy
All patients were informed in detail about the
risk and the benefits of each protocol, and a
written informed consent was obtained from
all of them

25. Demographic data of included
patients.
N = 60
Age / years
X ± SD 38.5 ± 11.8
Range 20-65
Number Percent (%)
Gender
Male 22 36.7
Female 38 63.3

26. The distribution of patients according to gender
38
22
Female
Male

27. Relation between Demographic data ,clinical history
and different study groups
I (n = 20) II (n = 20) III (n = 20) F P
Age / years
X ± SD 38.5 ± 11.8 39.1 ± 12.9 38.4 ± 11.4
Range 21- 60 20 - 65 23.65
0.03 0.96
No. (%) No. (%) No. (%) X2 P
Gender
Male 5 25 9 45 8 40
Female 15 75 11 55 12 60
1.87 0.39
History of acute cholecystitis 18 40 2 10 7 35 5.09 0.07
History of Jaundice 16 80 14 70 12 60 1.9 0.38
History of Pancreatitis 1 5 0 0 1 5 1.03 0.6

28. Intraoperative findings and
complications among studied group
I (n = 20) II (n = 20) III (n = 20) X2
P
1- Adhesions
Type 1 11(55.0) 5(25.0) 3(15.0)
Type 2 8(40.0) 6(30.0) 7(35.0)
Type 3 1(5.0) 8(40.0) 9(45.0) 15.52 0.04*
Type 4 0(0.00) 1(5.0) 1(5.0)
Viceral injury 0(0.0) 0(0.0) 0(0.0) 0 1
Intraoperative bleeding 1(5) 3(15) 1(5) 1.75 0.4
Gall bladder rupture 1(5) 2(10) 1(5) 0.54 0.76
Intraoperative CBD injury 0(0) 0(0) 1(5) 2.03 0.36
Conversion 0(0) 2(10) 1(5) 2.11 0.34
Operative time
X ± SD
39.5±15.5 54.7 ± 23 57.3 ± 19.1 4.7 0.012*

29. Percentage of Intraoperative adhesions among studied group
Group 1
05
5540
Type 1 type 2 Type 3 Type 4
Group II
5
40
25
30
Type 1 type 2 Type 3 Type 4
Group III
5
35
15
45
Type 1 type 2 Type 3 Type 4

30. Mean operative time in the studied groups
57.3
54.7
39.5
0
10
20
30
40
50
60
70
Group I Group II Group III
Meanoperativetime(min.)
Group I Group II Group III

31. Mean hospital stay in the studied groups
2.75
2
1.5
0
0.5
1
1.5
2
2.5
3
Group I Group II Group III
Meanhospitalstay(day)
Group I Group II Group III

32. Postoperative findings among studied groups
I (n = 20) II (n = 20) III (n = 20) X2
P
No % No % No % No %
Postoperative CBD injury 0 0 0 0 0 0 0 1
Postoperative collection 0 0 1 5 0 0 2.03 0.36
Postoperative wound
infection
1 5 4 20 2 10 2.26 0.3
Postoperative pain
Type 1 12 60 5 25 10 50
Type 2 7 35 10 50 8 40 6.7 0.1
Type 3 1 5 5 25 2 10
Hospital stay
X ±SD 1.5 ±0.6 2±0.8 2.75 ±2.3 3.61 0.03*
Range 1-3 1 – 4 1-10
Mortality 0 0 0 0 1

34. Among patients who undergo LC,
preoperative ERCP has been associated
with more frequent intraoperative and
postoperative complications and
conversion to open surgery .
Conversion to open surgery and
serious intra and post operative
complications did not show to be affected
by the time interval between ERCP and
Laparoscopic cholecystectomy

35. The main difference between the
groups showed to be in the score of
encountered intraoperative adhesions in
favor of the short interval group .
Shorter operative time and hospital stay
remarked in the early group with less cost
and earlier return to work

37. Translation of the research to practice
is the final aim of any research.
Our recommendation that early
LC(within 72 hours of ERCP) should be
the adopted policy because of less
adhesions, shorter operative time,
hospital stay
Further study is needed to evaluateFurther study is needed to evaluate
recurrent biliary symptomps during therecurrent biliary symptomps during the
waiting period and the conversion rate andwaiting period and the conversion rate and
complications in larger studiescomplications in larger studies

38. THANKTHANK
YOUYOU
THANKTHANK
YOU