Endoscopic/Laparoscopic Versus Open Surgical Management of Choledocholithiasis

Abstract

We recently read with interest the case report of Dr SheenChen and colleagues [1]. The clinical observation in relation to a markedly elevated serum CA 19-9 level being caused by choledocholithiasis is most interesting. Our major concern relates to the treatment rendered, namely the open surgical procedure which was described. No mention is made of a role for initial ERCP with endoscopic removal of the common bile duct (CBD) stone, with subsequent laparoscopic cholecystectomy. The other major option to pursue in the case under discussion would be that of laparoscopic cholecystectomy, with simultaneous laparoscopic common bile duct exploration (CBDE). Proceeding directly to laparotomy with open CBDE for treatment of choledocholithisis, as done in the case under discussion, does not appear to be the preferable approach at the present time, with the advent of endoscopic and laparoscopic equipment and techniques to treat this problem [2]. We presume concern over a biliopancreatic malignancy may have played a role, but the authors performed a fastidious pre-operative evaluation, which suggested a CBD stone to be the cause for the clinical scenario described. In addition, the authors themselves were apparently aware that benign CBD obstruction could be responsible for elevation of the serum CA 19-9 level, as elucidated in their paper. Given the considerations above, it is unclear why the authors chose to proceed directly to laparotomy with open CBDE for treatment of their patient who had choledocholithiasis, which was carefully diagnosed pre-operatively. The authors’ insight in this regard would be welcome.