LAUSR

I read this interesting paper regarding single-stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography. It compared the aforementioned method with laparoscopic common bile duct exploration (LCBDE), preand post-operative endoscopic retrograde cholangiopancreatography in the management of common bile duct (CBD) stones. There is no agreement on the matter of management, partly due to several variables, including the surgeon’s experience, which can affect the choice. Looking at the pros and cons of each of the above methods, there are two other variables that have been overlooked. The first variable is the size of the CBD stone and the second is the diameter of cystic duct. However, more importantly is the relationship between the two, which can determine the success or failure of LCBDE. A large stone in CBD simply is irretrievable through a smaller cystic duct and LCBDE is unlikely to be successful. If we have this information available before the operation, then we can decide in advance on the best method that suits the patient. Magnetic resonance cholangiopancreatography (MRCP), preferably the three-dimensional type, if available, is a safe technique which can be used to obtain this information with great accuracy before the operation. Adopting this approach can help us choose one of the following paths: first, if no stone is found in CBD, then the patient can be saved from undergoing any of the above procedures. Second, if the CBD stone is larger than the cystic duct, then the patient can either go to pre-operative endoscopic retrograde cholangiopancreatography or single-stage laparoscopic cholecystectomy and intraoperative endoscopic retrograde cholangiopancreatography depending on the available resources. Only if a small stone is found in the CBD can the patient go for LCBDE with confidence. Understandably, adopting the approach of routine or even selective pre-operative MRCP carries with it an additional cost but that is compensated by the savings made through not carrying out the other unnecessary procedures, saving of theatre time and saving of both the staff and the patients from unnecessary radiological exposure. In addition, MRCP has a much higher accuracy rate than ultrasound in diagnosing CBD stones, and there is a widespread trend to use it routinely pre-operatively. Furthermore, it can discover many abnormalities such as Mirizzi syndrome, avoiding unexpected surprises.