Laparoendoscopic Rendezvous for Difficult Cholecystocholedocholithiasis: A Prospective Cohort Study With Computed Tomography-Based Risk Stratification.

Abstract

Background: Selective biliary cannulation at endoscopic retrograde cholangiopancreatography (ERCP) is difficult in up to 40% of native papillae and drives post-ERCP pancreatitis (PEP) and incomplete common bile duct (CBD) clearance. Laparoendoscopic rendezvous (LERV) passes an antegrade transcystic guidewire across the papilla during laparoscopic cholecystectomy, a duodenoscope then completing sphincterotomy and extraction in one anesthetic. This study evaluated LERV in cholecystocholedocholithiasis pre-stratified as anticipated difficult cannulation by preprocedural computed tomography (CT).

Methods: In a single-centered prospective cohort study (June 2025-June 2026; NCT07008170), 80 consecutive adults underwent contrast-enhanced multidetector CT before surgery; the diagnosis rested on ultrasound, selective magnetic resonance cholangiopancreatography (MRCP) and biochemical criteria, MRCP not being universally available locally. Six radiologic predictors were recorded: worrisome periampullary diverticulum (PAD) score (0-2), papilla bulging, choledochoduodenal (CD) angle, distal CBD diameter, papilla location and a far-distal CBD stone. The primary outcome was technical success, a feasibility endpoint analyzed separately from duct clearance; secondary outcomes were CBD clearance, PEP, morbidity, and 60-day recurrence.

Results: Mean age was 52.4 ± 13.1 years and 56.3% were women. Technical success was 92.5% (74/80; 95% CI 84.6-97.2) and in-admission complete CBD clearance 95.0% (76/80). PEP occurred in 3/80 (3.8%; all mild), post-sphincterotomy bleeding and bile leak in 2/80 each (2.5%), cholangitis in 3/80 (3.8%) and perforation in 1/80 (1.3%), with no 30-day mortality. Technical success fell stepwise with the cumulative number of CT risk factors (Cochran-Armitage p < 0.001); a worrisome PAD score of 2 (odds ratio 9.4, 95% CI 1.7-52.8; p = 0.011) and a CD angle ≤ 20° (odds ratio 6.8, 95% CI 1.3-35.4; p = 0.024) independently predicted failure.

Conclusions: In a cohort whose papillary anatomy was characterized beforehand by CT, LERV achieved high in-admission CBD clearance with a low rate of mild PEP and no mortality. The CT features were associated with, but did not themselves produce, technical success; read from a CT already obtained for a clinical indication they may assist case selection, theater planning and consent. Where MRCP is universally available these measurements should be validated on that platform, and the associations require external validation.

Trial registration: ClinicalTrials.gov NCT07008170 (registered 15 June 2025).