Single-setting endoscopic retrograde cholangiopancreatography (ERCP) and cholecystectomy improve the rate of surgical site infection

Introduction: Cholecystectomy is a common surgical procedure. The presence of common bile duct stones complicates treatment, often requiring a second procedure for stone retrieval. For such patients, endoscopic retrograde cholangiopancreatography (ERCP) provides adequate therapy, and can be performed before, after, or at the same time as cholecystectomy. In 2013, duodenoscopes were implicated by the Centers for Disease Control and Prevention in transmission of carbapenem-resistant Enterobacteriaceae. In this study, we sought to determine if the addition of ERCP to cholecystectomy was associated with higher rates of surgical site infections and microbial resistance. Hypothesis: Adding ERCP to cholecystectomy increases the SSI rate. Methods: For this retrospective review, we used the SSI surveillance database at our tertiary-care academic hospital. Cholecystectomy cases between 2010 and 2015 were included in the analysis. SSI was diagnosed using criteria of CDC’s National Healthcare Safety Network (NHSN). We applied a logistic regression model to our data (SAS Studio software, v3.4, Enterprise Edition). Results: Our 6-year study period included 2201 cholecystectomies. The SSI rate was 4.1 times higher for patients who underwent open cholecystectomy as compared with laparoscopic cholecystectomy (95% CI 1.61–10.24). When adjusted for wound class and procedure type, the SSI rate was significantly higher for patients who underwent ERCP within 60 days before cholecystectomy (P = 0.04; OR 2.2; CI 1.04–4.49). Rates of resistant pathogens were significantly higher in patients who underwent ERCP in addition to cholecystectomy (1.1% vs. 0.2%, P = 0.02, Fisher’s exact test). Conclusions: ERCP performed in the same setting as cholecystectomy carries no increased risk of SSI and should be the treatment of choice in patients with choledocholithiasis. ERCP performed separately within 60 days before cholecystectomy doubles the risk of SSI. Contaminated equipment might play a role, but other factors are likely at play, and should be taken into account when selecting treatment pathways for patients with choledocholithiasis.