Background: The management of symptomatic or incidentally-discovered common bile duct (CBD) stones is still controversial. Of patients undergoing elective cholecystectomy for symptomatic cholelithiasis, 5-15% will also harbor CBD stones, and those with symptoms suggestive of choledocholithiasis will have an even with higher incidence. Options for treatment include preoperative ERCP with sphincterotomy (ERCP/ES) followed by laparoscopic cholecystectomy, laparoscopic cholecystectomy with intraoperative cholangiogram (LC/IOC), followed by either laparoscopic common bile duct exploration (LCBDE) or placement of a common bile duct double lumen catheter with postoperative management. The purpose of this analysis was to determine the optimal management of such patients.
Methods: A Decision Analysis was performed to analyze the management of patients with suspected common bile duct stones. The basic choice was between preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE or Common Duct Double Lumen Catheter (Fitzgibbons tube) placement with either expectant management or postoperative ERCP/LS. Data on morbidity and mortality was obtained from the literature. Sensitivity analysis was done varying the incidence of positive CBD stones on IOC with associated morbidity and mortality.
Results: One stage management of symptomatic CBD stones with LC/LCBDE is associated with less morbidity and mortality (7% and 0.19%) than two stage management utilizing preoperative ERCP/ES (13.5% and 0.5%). Sensitivity analysis shows that there is an increase in morbidity and mortality for LC/LCBDE as the incidence of positive IOC increases but are still less than two stage management even with a 100% positive IOC (9.4%, 0.5%). If a double lumen catheter is to be used for positive IOC, the morbidity would be higher than the two stage management only if the positive IOC incidence is more than 65% but still with no mortality.
Conclusion: LCBDE has a lower morbidity and mortality rates compared to preoperative ERCP/ES in the management of patients with suspected CBD stones even if the chance of CBD stones reaches 100%. Using a Common Duct Double Lumen catheter may be considered if LCBDE is not feasible and the chance of CBD stone is less than 65%.