TH2.4 Systematic Review on Surgical Management of Difficult Common Bile Duct stones

Abstract

Abstract Aims 85–95% of common bile duct stones (CBDS) are successfully managed with endoscopic treatment, but a small proportion of CBDS are difficult to remove. These lead to high morbidity secondary to complications of biliary obstruction. This study aims to appraise existing management options for difficult to retrieve CBDS through systematic review of existing published data. Methods Systematic literature search was performed on search engines including MEDLINE, EMBASE, Cochrane library and ClinicalTrials.gov using pre-defined search strategy and pre-registered in International Prospective Register of Systematic Review (PROSPERO). All studies regarding management options, efficacies and/or complications of difficult CBDS managements were included. Definition of difficult to clear CBDS were outlined. Results were independently reviewed, assessed for bias, analysed and reported using Preferred Reporting Items of Systematic Reviews and Meta-Analyses (PRISMA) guidelines. Results 59 studies were included through database search. Various difficult stone characteristics, surgical interventions and study designs were reported. Common bile duct exploration was shown to be the preferred management approach with good stone clearance. Stone clearance rate on CBD exploration and biliary enteric anastomoses were found to be overall above 83% among reviewed studies. Adjunctive strategies, particularly laser lithotripsy, were of additional beneficial value in clearing difficult stones. Overall complication rates were found to be low, and majority did not require significant intervention. However, included data were heterogenous and of high risk of biases. Conclusion Current evidence suggests good outcomes from surgical management of difficult choledocholithiasis, but evidence is of heterogenous quality. Further randomised controlled trials are warranted to explore preferable management options.