Common duct exploration or endoscopic sphincterotomy for choledocholithiasis?

Abstract

The relative indications for operative common duct exploration (CDE) and endoscopic sphincterotomy (ES) in treating common duct stones are often unclear. This prospective study compared CDE and ES in treating choledocholithiasis after excluding patients with acute cholecystitis, idiopathic pancreatitis, sphincter of Oddi dysfunction and malignant disease. One hundred and two patients had 105 CDE and a further 50 patients had 57 ES. Of the patients having CDE, 76 also had cholecystectomy for gall-bladder (GB) disease while 26 had prior cholecystectomy. With ES, in 16 the GB was present and not removed while 34 patients had had prior cholecystectomy. Hospitalization was significantly less following ES. There was one peri-operative death after CDE and none after ES. There were two late biliary-related deaths, 3 and 27 months after ES, in patients who developed acute cholecystitis. In post-cholecystectomy patients having ES, complications were fewer and less severe after ES (15%) than CDE (41%). In patients with an intact GB, peri-operative complications occurred in 30% after cholecystectomy and CDE. Following ES alone, complications occurred in 33% with the majority of these complications arising from the diseased GB. It is concluded that the optimal treatment for post-cholecystectomy patients with bile-duct stones is ES. In elderly patients with an intact GB, the bile-duct stones can be treated by ES; whether subsequent cholecystectomy is necessary should be assessed on the likelihood of future GB complications.