EUS Prior to ERCP in the Positive Setting of Positive Intraoperative Cholangiogram (IOC) During Cholecystectomy
Condition: Calculi; Stenosis of Bile Duct
MeSH terms: Calculi
Study type: Observational

Summary: 
      Performing an EUS prior to ERCP in the setting of a positive intraoperative cholangiogram
      will identify and risk stratify patients for the presence of CBD stones and strictures.
    

Detailed description: 
      During routine cholecystectomy, surgeons will often perform an intraoperative cholangiogram
      in an effort to define anatomical landmarks and ensure patency and drainage of the common
      bile duct. This involves injecting a radiopaque contrast medium into the biliary tree during
      the operation. Occasionally contrast injection onto the common bile duct will reveal an
      abnormality and are deemed a "positive intraoperative cholangiogram" (positive IOC). These
      abnormalities can include the following: single or multiple stones; non-filling of the
      duodenum by contrast; stenosis or narrowing of the common bile duct (CBD). When discovered
      these findings are better addressed and treated endoscopically via endoscopic retrograde
      cholangiopancreatography (ERCP). ERCP's are considered the gold standard for the diagnosis
      and treatment of positive intraoperative cholangiograms. However, several studies have shown
      that 40-50% of patients who undergo an ERCP after a "positive" IOC have a normal
      cholangiogram. Reasons for this include spontaneous stone passage of the stone, dysmotility
      of the biliary tree, or poor quality, incomplete, or misinterpretation of the IOC. Therefore
      ERCP's are being performed when they could be avoided. ERCP performance carries significant
      complications including pancreatitis (5-10%), bleeding, and perforation. Ideally if a safer
      test to assess the bile duct could be performed immediately prior to the ERCP to confirm the
      presence of the positive IOC findings, this would ensure that the ERCP is being performed for
      therapeutic means thus avoiding unnecessary ERCP's.

      EUS is often performed prior to ERCP's under the same sedation in our endoscopy unit. From
      2005 to 2007, two hundred and twenty seven "combined EUS and ERCP procedure were
      performed.(unpublished internal data). Our experience with "combined" EUS and ERCP procedures
      has demonstrated that performing an EUS prior to an ERCP will prolong the total procedure
      time less than 10 minutes with no significant increase in adverse events. Performance of an
      EUS prior to ERCP to confirm biliary pathology after a "positive" IOC has never been studied
      in a rigorous fashion.
    

Observational model: Cohort
Time perspective: Prospective
Sampling method: Non-Probability Sample
Study population: 
        Patients who have gone an uncomplicated cholesytectomy and determined to have a "positive
        intraoperative cholangiogram" within one month of presentation to Wake Forest Baptist
        Health.
      
Keywords: EUS; ERCP; Intraoperative cholangiogram; Cholecystectomy; Common Bile Duct Stones; Strictures; Stenosis; Duodenum; Dilated Bile duct; Non-filling of the duodenum by contrast