Management of Preoperatively Suspected Choledocholithiasis: a Decision Analysis

Overview

Journal J Gastrointest Surg

Specialty Gastroenterology

Date 2008 Aug 7

PMID 18683008

Citations 29

Authors

Bilal Kharbutli

Vic Velanovich

Affiliations

Soon will be listed here.

Abstract

Background: The 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.

Methods: A 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.

Results: One-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.

Conclusion: LCBDE 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%.

Citing Articles

Is there a role for routine intraoperative cholangiogram in diagnosing CBD stones in patients with normal liver function tests? A prospective study.

Lim Y, Leow V, Koong J, Subramaniam M Innov Surg Sci. 2024; 9(1):37-45.

PMID: 38826633 PMC: 11138406. DOI: 10.1515/iss-2023-0059.

Comparing One-Stage vs Two-Stage Approaches for the Management of Choledocholithiasis.

Kattih O, Velanovich V J Gastrointest Surg. 2022; 27(3):534-543.

PMID: 36127555 DOI: 10.1007/s11605-022-05458-y.

Routine intraoperative cholangiography during laparoscopic cholecystectomy: application of the 2016 WSES guidelines for predicting choledocholithiasis.

Lai H, Tsai K, Chen H Surg Endosc. 2021; 36(1):461-467.

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Comparison on the Efficacy of Three Duct Closure Methods after Laparoscopic Common Bile Duct Exploration for Choledocholithiasis.

Qin A, Wu J, Qiao Z, Zhai M, Lu Y, Huang B Med Sci Monit. 2019; 25:9770-9775.

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Consequences of Stenting and Endoscopic Papillary Balloon Dilatation in Treatment of Large and Multiple Common Bile Duct Stones.

Hormati A, Ghadir M, Hasanpour Dehkordi A, Yadollahi F, Salehitali S, Afifian M Middle East J Dig Dis. 2019; 11(4):205-210.

PMID: 31824623 PMC: 6895848. DOI: 10.15171/mejdd.2019.150.

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