HPB SO59 - How do Previous Biliary Interventions Affect the Operative and Postoperative Outcomes Of Patients Undergoing Laparoscopic Cholecystectomy (LC) and Bile Duct Exploration (LCBDE)?

Abstract Background Laparoscopic biliary surgery is perceived to be difficult in patients who had undergone previous biliary interventions; ERCP, cholecystostomy or cholecystectomy. Our objective was to evaluate the referral pattern, the preoperative characteristics and operative and postoperative outcomes in such patients. Method Analysis of prospectively collected data from patients treated by a specialist biliary unit dedicated to index admission LC and single session laparoscopic management of bile duct stones. In spite of a policy of no preoperative endoscopic clearance of bile duct stones the unit inevitably received some patients who had had previous ERCP at other hospitals prior to referral or were initially unfit when admitted to the base hospital and required ERCP. In a series of 6140 LC and LCBDE 158 patients (2.57%) had already undergone ERCP and 31 (0.5%) had undergone cholecystectomies (18), cholecystostomies (9) or attempted cholecystectomy. Results Of 158 pre-referral ERCPs, 130 (82.3%) were referred from other hospitals, 36 (22.8%) having had more than one ERCP. 83.5% had suspected CBD stones. LC difficulty grade was IV to V in 48.7%. 112 patients (70.9%) required LCBDE. There were 10.1% biliary related complications, 3 re-operations, one conversion and one mortality. of 31 patients with previous biliary interventions, 58% came from other units or hospitals. A third had already undergone ERCP. 61.3% had LC difficulty grades IV or V. The 18 un-cholecystectomised patients needed LCBDE with no conversions or bile duct injuries. There were only 2 (6.5%) biliary related complications. Conclusion While previous biliary interventions understandably increased the difficulty of LC they did not adversely affect operative and postoperative outcomes. Such surgery should be undertaken in the specialist setting as 70.9% of those with previous endoscopic and 58.1% of those with previous surgical or radiologically guided biliary interventions require LCBDE. Implementing definitive surgical interventions during the index admission can achieve a substantial reduction in re-admission rates, and overall decrease in hospital episodes without significant morbidity, re-interventions or mortality. This enhances the quality of life for patients who would otherwise be subjected to multiple repeat ERCPs and yields significant cost benefits.