Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?

Abstract

Objective: To evaluate treatments for common bile duct stones (CBDS).

Design: Retrospective review of authors' case series.

Setting: Large private metropolitan teaching hospital.

Patients: All patients with CBDS (N = 145) from a series of 1231 patients who underwent laparoscopic cholecystectomy, 99% with intraoperative fluorocholangiography.

Interventions: Treatments for CBDS included one or more of the following: laparoscopic transcystic duct exploration (n = 123), laparoscopic choledochotomy (n = 10), open choledochotomy (n = 7), preoperative endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2), post-operative ES (n = 11), or observation (n = 10).

Main outcome measures: Success of various interventions for CBDS, morbidity and mortality, frequency of retained stones, operative time, and length of postoperative hospitalization.

Results: Laparoscopic transcystic duct exploration was successful in 91% of attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sphincterotomy was successful in 56% of preoperative attempts, 50% of intraoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death.

Conclusions: For patients requiring cholecystectomy, laparoscopic transcystic duct exploration is safe and effective, treats CBDS in one session, and if unsuccessful still allows for open choledochotomy or postoperative ES. Preoperative endoscopic retrograde cholangiography and ES should be reserved for patients with serious illness or possible malignant disease.