Introduction: Two recent meta-analyses support operative common bile duct (CBD) exploration (laparoscopic or open) as at least equal to endoscopic retrograde cholangiopancreatography (ERCP) for the management of choledocholithiasis with the gall bladder in situ. Much of the literature regarding laparoscopic exploration comes from enthusiasts of the technique and may not be transferable to other institutions. In our institution both hepatobiliary and general surgeons perform cholecystectomy with a variable comfort level with laparoscopic CBD exploration. ERCP and laparoscopic antegrade transampullary biliary stents are available. We review the management of choledocholithiasis in this setting.
Methods: A retrospective review of all patients who underwent cholecystectomy during 2004 and 2005 at two hospitals in Newcastle, Australia was conducted.
Results: The incidence of choledocholithiasis was 10.3% (70 of 681 patients who underwent cholecystectomy). Of the 36 patients with choledocholithiasis diagnosed pre-operatively, 22 underwent pre-operative ERCP (62.5% clearance rate) and 14 underwent planned operative CBD exploration (100% clearance). In addition, a normal pre-operative ERCP was performed in 22 patients with presumed choledocholithiasis. Operative cholangiogram first confirmed choledocholithiasis in 31 patients; CBD exploration in these patients was successful in 10 of 17 (58.8%). Fifteen patients had antegrade stents inserted due to a small calibre or friable CBD, failed CBD exploration, or lack of equipment and time for operative exploration. Hepatobiliary surgeons more frequently performed CBD exploration and the placement of intra-operative stents.
Conclusion: The management of common bile duct stones will vary depending on the clinical scenario and local expertise. This series defines a role for intra-operative antegrade stent placement, suggests pre-operative ERCP is over-utilised, and that operative CBD exploration is successful with low morbidity.