Choledocholithiasis: evolving standards for diagnosis and management

Abstract

Cholelithiasis, one of the most common medical conditions leading to surgical intervention, affects approximately 10 % of the adult population in the United States. Choledocholithiasis develops in about 10%-20% of patients with gallbladder stones and the literature suggests that at least 3%-10% of patients undergoing cholecystectomy will have common bile duct (CBD) stones. CBD stones may be discovered preoperatively, intraoperatively or postoperatively Multiple modalities are available for assessing patients for choledocholithiasis including laboratory tests, ultrasound, computed tomography scans (CT), and magnetic resonance cholangiopancreatography (MRCP). Intraoperative cholangiography during cholecystectomy can be used routinely or selectively to diagnose CBD stones. The most common intervention for CBD stones is ERCP. Other commonly used interventions include intraoperative bile duct exploration, either laparoscopic or open. Percutaneous, transhepatic stone removal other novel techniques of biliary clearance have been devised. The availability of equipment and skilled practitioners who are facile with these techniques varies among institutions. The timing of the intervention is often dictated by the clinical situation.

Figure 1

Intraoperative cholangiogram via the cystic duct demonstrating proximal biliary dilation and two filling defects in the CBD (Arrows).

Figure 2

Laparoscopic view of a choledochoscope (CS) entering the CBD via the cystic duct. The gallbladder (GB) is retracted to the left of the image.

Figure 3

CBD stone as seen through the choledochoscope.