Management of cholelithiasis with choledocholithiasis: Endoscopic and surgical approaches

Abstract

Gallstone disease and complications from gallstones are a common clinical problem. The clinical presentation ranges between being asymptomatic and recurrent attacks of biliary pain requiring elective or emergency treatment. Bile duct stones are a frequent condition associated with cholelithiasis. Amidst the total cholecystectomies performed every year for cholelithiasis, the presence of bile duct stones is 5%-15%; another small percentage of these will develop common bile duct stones after intervention. To avoid serious complications that can occur in choledocholithiasis, these stones should be removed. Unfortunately, there is no consensus on the ideal management strategy to perform such. For a long time, a direct open surgical approach to the bile duct was the only unique approach. With the advent of advanced endoscopic, radiologic, and minimally invasive surgical techniques, however, therapeutic choices have increased in number, and the management of this pathological situation has become multidisciplinary. To date, there is agreement on preoperative management and the need to treat cholelithiasis with choledocholithiasis, but a debate still exists on how to cure the two diseases at the same time. In the era of laparoscopy and mini-invasiveness, we can say that therapeutic approaches can be performed in two sessions or in one session. Comparison of these two approaches showed equivalent success rates, postoperative morbidity, stone clearance, mortality, conversion to other procedures, total surgery time, and failure rate, but the one-session treatment is characterized by a shorter hospital stay, and more cost benefits. The aim of this review article is to provide the reader with a general summary of gallbladder stone disease in association with the presence of common bile duct stones by discussing their epidemiology, clinical and diagnostic aspects, and possible treatments and their advantages and limitations.

Keywords: Choledocholithiasis; Endoscopic retrograde cholangio-pancreatography; Gallbladder stones; Laparoscopic cholecystectomy; Management of biliary lithiasis; Rendezvous technique.

Figure 1

Intraoperative images: Laparoscopic exploration of the common bile duct. A: Common bile duct (CBD) dilation; B: CBD section; C: Stone extraction; D: Insertion of the choledochoscope into the CBD; E: Choledochoscopic image of the CBD; F: Suture of CBD.

Figure 2

Intraoperative images: Endoscopic retrograde cholangio-pancreatography during laparoscopic cholecystectomy (“rendezvous technique”). A: Insertion of the guide wire into the cystic duct; B: Guide wire exits through the papilla into the duodenum; C: Endoscopic sphincterotomy on guide wire; D: Extraction of stones from the common bile duct with a dormia basket; E: Section between clips of the cystic duct and subsequent retrograde cholecystectomy; F: Postoperative final scars.