Intraoperative rendezvous endoscopic retrograde cholangiopancreatography for choledocholithiasis: what about big stones?

I read with great interest the recent article by Ràbago et al. [1]. The authors are to be congratulated on this prospective randomized study of patients with choledocholithiasis in which they compared preoperative endoscopic retrograde cholangiopancreatography (ERCP) followed by cholecystectomy with intraoperative ERCP (using the rendezvous technique) during cholecystectomy. The results were convincingly in favor of intraoperative ERCP, with less morbidity, a shorter hospital stay, and reduced costs.

The authors do not give detailed information about the size or the number of bile duct stones retrieved in either group. Because of the randomization, one might imagine that the distribution of these parameters in the two groups was comparable. We have used the intraoperative rendezvous technique for the last 5 years. Our experience is that the technique might be less suitable for patients with numerous and/or bigger bile duct stones (where the number and size are known preoperatively). In fact, in these cases, the surgical team can lose time because they have to wait until extraction is achieved. We also have the impression that the extraction angle needed for removing numerous and/or big stones is somewhat more difficult to achieve in the supine position that is needed for intraoperative ERCP than it is in the classic prone or left-lateral positions usually used for ERCP.

The paper gives a very good insight into the technical aspects of the rendezvous procedure. I would just add that it is necessary in some cases to retract the guide wire back into the main common bile duct and then insert it into the intrahepatic bile ducts when stones are discovered above the cystic duct.

Competing interests: None

References

• 1 Ràbago L R, Vicente C, Soler F. et al . Two-stage treatment with preoperative endoscopic retrograde cholangiopancreatography (ERCP) compared with single-stage treatment with intraoperative ERCP for patients with symptomatic cholelithiasis with possible choledocholithiasis.  Endoscopy. 2006;  38 779-786