A stepwise approach in the management of choledocholithiasis – balancing the risk of bile duct exploration and adequate duct clearance

Abstract

Introduction: Choledocholithiasis is present in 3% to 15% of patients with symptomatic gallstones. It can be managed at time of laparoscopic cholecystectomy. This is particularly relevant if there is no local endoscopic retrograde cholangiopancreatography (ERCP) expertise. Method: Transcystic catheter with a basket or choledochoscopic exploration comes with the potential risk of bile duct injury. Ultimately balancing this risk against the risk of retained choledocholithiasis from suboptimal bile duct clearance is paramount. A stepwise approach may assist in limiting the use of the transcystic basket or choledochoscope where this is absolutely necessary. Result: Our proposed stepwise approach in the management of choledocholithiasis is as follows: 1. Buscopan, glucagon, and/or saline flushing via cholangiogram catheter 2. Passage of cholangiogram catheter into the duodenum 3. Fluoroscopy-guided basket extraction 4. Choledochoscopy-guided basket extraction 5. Transpapillary stent placement when postoperative ERCP is required Passage of the cholangiogram catheter can be considered before basket or choledochoscopic exploration because it establishes that the cystic duct – bile duct junction can be safely traversed. It may also facilitate passage of gravel or fine stones in the distal bile duct into the duodenum without necessitating the use of basket along with the added risk from this. Conclusion: This stepwise approach allows reserving the use of the transcystic basket to a potentially smaller subset of patients with the aim of reducing the overall risk of bile duct exploration.