Identification and treatment of common bile duct stones before cholecystectomy

Abstract

The classical management of common duct stones associated with gall bladder stones is cholecystectomy and common bile duct exploration. This approach gives excellent results, but is associated with a mortality rate in the 2% range [1] and an incidence of recurrent or residual stones of 4% to 10% [2, 3]. This incidence is higher in the more aged population and in patients with complications of stones such as cholangitis or jaundice. The last two decades have seen the development of new technology which has called into question the appropriateness of this classical approach. Improved methods are now available for pre and intraoperative identification of common bile duct stones and the capability now exists for carrying out stone extraction via endoscopic means without laparotomy. These procedures are however associated with their own risks and complications. How has this affected the clinical indications for common bile duct exploration? This paper will review some of the current literature on the subject as well as presenting a synopsis of three papers given at the first World Congress of Hepato Pancreato Biliary Surgery in Sweden in June 1986 and then attempt to answer the following questions: 1. How vigorously should one pursue the investigation for common bile duct stones in patients with known gall stones? 2. When coincidental common bile duct and gall bladder stones are identified, what is the preferred approach a) preliminary ERCP and papillotomy and removal of stones only? b) ERCP, papillotomy, removal of stones followed by elective cholecystectomy? c) operative cholecystectomy and common bile duct exploration?