# CHOLECYSTECTOMY WITH INTRAOPERATIVE ENDOSCOPIC RETROGRADE CHOLANGIOPANCREATOGRAPHY: DOES THE ORDER MATTER?

## TL;DR

This study examines whether the order of cholecystectomy and ERCP affects outcomes in treating gallstones and bile duct stones.

## Contribution

It is the first to analyze the impact of procedure order on success rates and complications in a single surgical session.

## Key findings

- Performing ERCP first was associated with higher success in bile duct cannulation.
- Lymphopenia and cholecystitis were linked to failure in clearing the bile duct.
- Procedure order did not significantly affect overall complications or bile duct clearance success.

## Abstract

The recommended treatment for cholecystocholedocholithiasis is cholecystectomy (CCT) associated with endoscopic retrograde cholangiopancreatography (ERCP). CCT with intraoperative ERCP is associated with higher success rates and lower hospital stays and hospital costs. However, some case series do not describe the exact methodology used: whether ERCP or CCT was performed first.

Verify if there is a difference, in terms of outcomes and complications, when intraoperative ERCP is performed immediately before or after CCT.

This is a retrospective case-control study analyzing all patients who underwent CCT with intraoperative ERCP between January 2021 and June 2022, in a tertiary hospital in southern Brazil, for the treatment of cholecystocholedocholithiasis.

Out of 37 patients analyzed, 16 (43.2%) underwent ERCP first, immediately followed by CCT. The overall success rate for the cannulation of the bile duct was 91.9%, and bile duct clearance was achieved in 75.7% of cases. The post-ERCP pancreatitis rate was 10.8%. When comparing the "ERCP First" and "CCT First" groups, there was no difference in technical difficulty for performing CCT. The "CCT First" group had a higher rate of success in bile duct cannulation (p=0.020, p<0.05). Younger ages, presence of stones in the distal common bile duct and shorter duration of the procedure were factors statistically associated with the success of the bile duct clearance. Lymphopenia and cholecystitis as an initial presentation, in turn, were associated with failure to clear the bile duct.

There was no significant difference in terms of complications and success in clearing the bile ducts among patients undergoing CCT and ERCP in the same surgical/anesthetic procedure, regardless of which procedure was performed first. Lymphopenia and cholecystitis have been associated with failure to clear the bile duct.