Managing choledocholithiasis in the laparoscopic era

Abstract

Background: Management options for common bile duct stones have expanded in the era of laparoscopic cholecystectomy (LC), and selecting the most appropriate method for each patient can be problematic due to the difficulty of predicting accurately which patients have choledocholithiasis (CDL). In order to improve selection of appropriate treatment for CDL, treatment options were analyzed for outcome retrospectively during a 25-month period beginning June 1, 1992. Patients and methods: Four hundred four patients underwent LC; 48 (12%) had CDL identified at preoperative endoscopic retrograde cholangiopancreatography (ERCP) or intraoperative cholangiogram (IOCG). Forty-seven patients were referred for preoperative ERCP for suspected CDL, 23 (49%) of whom had proven duct stones and underwent endoscopic sphincterotomy and stone retrieval with an 87% success rate. Results: Of 357 patients scheduled for LC without preoperative ERCP, 236 had IOCG, of which 25 (11%) demonstrated CDL. Seven patients had open common bile duct exploration (CBDE). Sixteen patients had postoperative ERCP after positive IOCG, 7 (44%) of which were positive for CDL and whose stones were removed with 100% success. Two patients were observed, anticipating spontaneous passage of a small stone. Conclusions: Preoperative ERCP should be applied selectively. For the large majority of patients without preoperative evidence of CDL, we recommend routine IOCG; if CDL is demonstrated, an intraoperative decision can be made to proceed to postoperative ERCP in the usual case or to open CBDE for very large or multiple stones. Observation in anticipation of spontaneous passage may be appropriate for small, solitary common duct stones. Continuing advances in laparoscopic CBDE are likely to reduce further the need to rely on ERCP in managing CDL.