PubMed · 3132473
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J P Kassirer, R I Kopelman. 1988-06-15. Surprise!. https://doi.org/10.1080/21548331.1988.11703481
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Bile duct stones are associated with a high rate of severe complications such as bile duct obstruction, cholangitis and biliary pancreatitis; therefore, stones of the common bile duct should always be removed. Today the endoscopic sphincterotomy and stone removal are the therapy of choice. When the gallbladder is still present, the duct stones should be removed endoscopically before laparoscopic cholecystectomy. For difficult bile duct stones, various procedures like mechanical lithotripsy, intracorporeal shock wave lithotripsy (ISWL), intracorporeal laser lithotripsy (ILL) and extracorporeal shock wave lithotripsy (ESWL) have been shown to increase the success rate of duct clearance to up to 95 to 100%. Before laparoscopic cholecystectomy, an ERCP should be performed, if there is a history or repeated biliary colic pain, cholangitis or biliary pancreatitis, if on ultrasound the diameter of the common bile duct is greater than 6mm, or if there are signs of cholestasis in the laboratory. In acute cholangitis, urgent endoscopic sphincterotomy has been shown to decrease the morbidity and mortality rate compared to surgical interventions. In acute biliary pancreatitis, early sphincterotomy also decreases the rate of morbidity significantly.
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OBJECTIVE: To evaluate treatments for common bile duct stones (CBDS). DESIGN: Retrospective review of authors' case series. SETTING: Large private metropolitan teaching hospital. PATIENTS: All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography. INTERVENTIONS: Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10). MAIN OUTCOME MEASURES: Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization. RESULTS: Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death. CONCLUSIONS: For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.