Management of Preoperatively Suspected Choledocholithiasis: A Decision Analysis

Abstract

BackgroundThe management of symptomatic or incidentally discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5–15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even higher incidence. Options for treatment include preoperative endoscopic retrograde cholangiopancreatography (ERCP) with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double-lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients. MethodsA decision analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, or common duct double-lumen catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/ES. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality. ResultsOne-stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two-stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two-stage management even with a 100% positive IOC (9.4%, 0.5%). If a double-lumen catheter is to be used for positive IOC, the morbidity would be higher than two-stage management only if the positive IOC incidence is more than 65% but still with no mortality. ConclusionLCBDE has lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a common duct double-lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.