Laparo-endoscopic “Rendezvous” to treat cholecysto-choledocolithiasis: Effective, safe and simplifies the endoscopist’s work

Table 1 Main differences for the endoscopist between the main steps of endoscopic procedures at the papilla of Vater for CBD exploration comparing RV with standard ERCP-ES

Factors of difference of the endoscopic procedure	RV	ERCP-ES
(1) Position of the patient	Supine	Lateral
	Rarely more difficult endoscopy	Preferred because of habit
(2) Cholangiography	Antegrade transcystic	Retrograde
	Positive (time reduction)	Negative
(3) Wirsung injection (chemical damage)	Absent	Possible
	Positive (risk reduction)	Negative
(4) Ductal hyperpression (physical damage)	Absent	Frequent
	Positive (risk reduction)	Negative
(5) Guide wire help for papilla cannulation	Transcystic	Retrograde
	Positive (time reduction)	Negative
(6) Flushing of the CBD	Antegrade during basket retrieval (synergic)	Retrograde
	Positive (time reduction)	Not synergic
(7) Papilla manipulation causing oedema or Oddi’s spasm	Limited or absent	Frequent
	Positive (risk reduction)	Negative
(8) Precut of the Papilla	Absent	Possible
	Positive (risk reduction)	Negative
(9) Reduction of the steps of endoscopic procedure	Possible	Uncommon
	Positive (time reduction)	Negative
Total of positive factors	8/9	1/9

Table 2 Main indications for the laparo-endoscopic RV with evaluation of the factors that suggest its preferability instead of the other treatment’s options

Main indications for the laparo-endoscopic RV	RV preferable vs laparoscopic CBD exploration	RV preferable vs sequential ERCP-ES
(1) Common bile duct stones not easily extractable	(A) Need of higher surgical skill	(a) Risk of synchronization
through the cystic duct	(B) Longer operation time	(b) Risk of unnecessary ERCP
Positive factor -> (time reduction)	(C) Need of biliary drain	(c) Risk of difficult retrograde cannulation
(2) Multiple small CBD stones and large friable stones	A, B, C +	a, b, c
Positive factor -> (reduction of risk of recurrence )	(D) High risk of residual fragments and recurrence
(3) Any type of CBD stones with delayed passage of the contrast medium during IOC or T-tube-IOC after laparoscopic CBD exploration	A, B, C, D + (E) high risk of undertreatment of chronic papillitis and of maintenance of underlying causes	a, b, c
Positive factor -> (reduction of risk of recurrence)
(4) CBD stones with previous cholangitis	A, B, C, D +	a, b, c +
Positive factor -> (reduction of risk of recurrence)	(E) high risk of maintenance of underlying causes at the papilla	(d) Avoidance of contrast medium injection with risk of recurrence of cholangitis
(5)CBD stones after recurrent acute biliary pancreatitis or hyperbilirubinemia Positive factor -> (iatrogenic risk reduction)	A, B, C, D, E	a, b, c, d +(e) risk of recurrence of ERCP related acute pancreatitis
(6) Known or unsuspected Sphincter of Oddi Dysfunction, cholecysto-lithiasis with or without CBD stones	A, B, C, D, E	a, b, c, d, e
Positive factor -> (iatrogenic risk reduction)
(7) CBD stones and/or abovementioned problems in patients with Billroth II during open cholecystectomy Positive factor -> (iatrogenic risk reduction)	A, B, C, D, E + (F) Manual drive of the endoscope by the surgeon in the afferent jejunal loop	a, b, c, d, e + (f) more difficult ERCP
(8) CBD stones, SOD, acute pancreatitis in children/CBD stones in patients with normal or thin CBD Positive factor -> (iatrogenic risk reduction)	A, B, C, D, E +(G) difficult laparoscopic CBD exploration and risk of stenosis of the suture	a, b, c, d, e, f +(h) avoidance of sphincterotomy in children
(9) CBD stones and/or SOD after failure of preoperative ERCP-ES or recurrence of acute biliary pancreatitis	A, B, C, D, E	a, b, c, d, e, f
Positive factor -> (iatrogenic risk reduction)
(10) Inexperienced surgeon for laparoscopic CBD exploration	A, B, C, D, E, G	a, b, c, d, e, f
Positive factor -> (iatrogenic risk reduction)