Common bile duct (CBD) stone is a relatively frequent disorder with a prevalence of 10-20% in patients with gallstones. This is also associated with serious complications, including obstructive jaundice, acute suppurative cholangitis, and acute pancreatitis. Early diagnosis and prompt treatment is the most important for managing CBD stones. According to a recent meta-analysis, endoscopic ultrasonography and magnetic resonance cholangiopancreatography have high sensitivity, specificity, and accuracy for the diagnosis of CBD stones. Endoscopic ultrasonography, in particular, has been reported to have higher sensitivity between them. A suggested management algorithm for patients with symptomatic gallstones is based on whether they are at low, intermediate, or high probability of CBD stones. Single-stage laparoscopic CBD exploration and cholecystectomy is superior to endoscopic retrograde cholangiopancreatography (ERCP) plus laparoscopic cholecystectomy with respect to technical success and shorter hospital stay in high risk patients with gallstones and CBD stones, where expertise, operative time, and instruments are available. ERCP plus laparoscopic cholecystectomy is usually performed to treat patients with CBD stones and gallstones in many institutions. Patients at intermediate probability of CBD stones after initial evaluation benefit from additional biliary imaging. Patients with a low probability of CBD stones should undergo cholecystectomy without further evaluation. Endoscopic sphincterotomy and endoscopic papillary balloon dilation in ERCP are the primary methods for dilating the papilla of Vater for endoscopic removal of CBD stones. Endoscopic papillary large balloon dilation is now increasingly performed due to the usefulness in the management of giant or difficult CBD stones. Scheduled repeated ERCP may be considered in patients with high risk of recurrent CBD stones.
Keywords: Cholangiopancreatography, endoscopic retrograde; Choledocholithiasis; Gallstones.
In this case, given the patient’s age and comorbidities it was decided that this was the treatment of choice. Biliary drainage was achieved during initial ERCP using a pigtail stent.
The main complication is cholangitis (1%–8%) and this is reduced by use of prophylactic antibiotics. 1, 6 Procedure related mortality has not been reported.
Q2: What does the post-treatment ercp film (fig1 in questions; see p 178) show?
Spontaneous passage of calculi occurs in up to 10% of patients, with 80% requiring removal of stone fragments during repeat ERCP. 1 Although recurrence of bile duct calculi is estimated at 14% after one year, most of these are amenable to endoscopic treatment. 2
These are summarised in fig 1. Endoscopic extraction of common bile duct stones after spincterotomy and mechanical lithotripsy has a success rate of up to 95% and is considered the treatment of choice. 1, 2 The reason for failure in this case was the large size of the bile duct calculus. Other reasons include bile duct strictures, unusual anatomy, and calculi beyond reach of the wire basket. 1– 3
Traditionally such patients have been referred for surgical exploration of the common bile duct but this procedure is not without risk, particularly in elderly patients or those with major medical comorbidities. 4
Included in this prospective study cohort were all patients with CBDS and gallbladder stones treated with laparoscopic common bile duct stone extraction (LCBDE) at the Nanjing Drum Tower Hospital and the 101st hospital of the People Liberation Army in China over the period from May 2000 to February 2009. We collected and analyzed patient clinical presentations, laboratory test results, ultrasonography, magnetic resonance cholangiopancreatography (MRCP), or intraoperative cholangiography (IOC). Patient consent for endoscopic surgery and research was obtained before the procedure was started. The study protocol was approved by the Ethics Committee of the Nanjing Drum tower Hospital and the 101st hospital. The protocol was implemented in accordance with provisions of the Declaration of Helsinki and Good Clinical Practice guidelines.
From May 2000 to February 2009, we prospective treated 346 consecutive patients with gallbladder stones and CBDS with laparoscopic cholecystectomy and LCBDE. Intraoperative findings, postoperative complications, postoperative hospital stay and costs were analyzed.
In the majority of LTSE patients, the cystic duct was narrow and needed to be dilated. Dilatation was carried out first with blunt, flexible dilators introduced by a 10-mm trocar inserted upright to the cystic duct opening. After dilation, a 5-mm flexible choledochoscope was introduced into the cystic duct. Small stones were flushed out through the papilla.In the majority of cases, stones were extracted with a Dormia basket (Boston Scientific Corporation, USA) under choledochoscopic control. After extraction, a completion cholangiography was performed to detect any upper bile duct stones. If the finding was negative, then the cystic duct was closed with a hem-o-lok clip (Teleflex Medical Inc, USA). Abdominal drainage was not routinely placed unles ssevere acute cholecystitis occurred.