Modern approach to cholecysto-choledocholithiasis

Abstract

Gallstones and common bile duct calculi are found to be associated in 8%-20% of patients, leading to possible life-threatening complications, such as acute biliary pancreatitis, jaundice and cholangitis. The gold standard of care for gallbladder calculi and isolated common bile duct stones is represented by laparoscopic cholecystectomy and endoscopic retrograde cholangiopancreatography, respectively, while a debate still exists regarding how to treat the two diseases at the same time. Many therapeutic options are also available when the two conditions are associated, including many different types of treatment, which local professionals often administer. The need to limit maximum discomfort and risks for the patients, combined with the economic pressure of reducing costs and utilizing resources, favors single-step procedures. However, a multitude of data fail to strongly demonstrate the superiority of any technique (including a two or multi-step approach), while rigorous clinical trials that include so many different types of treatment are still lacking, and it is most likely unrealistic to conduct them in the future. Therefore, the choice of the best management is often led by the local presence of professional expertise and resources, rather than by a real superiority of one strategy over another.

Keywords: Bile duct stones; Cholecystolithiasis; Common bile duct stones; Endoscopic retrograde cholangiography; Endoscopy; Laparo-endoscopic; Laparoendoscopic rendezvous; Laparoscopy.

Figure 1

A proposed algorithm for a combined-multimodal approach to cholecysto-choledocholithiasis. CCL: Cholecysto-choledocholithiasis; ERC: Erythropoietin-responsive cells; RVT: Rendez-vous Technique; LCC: Laparoscopic cholecystectomy.