The relationship between complex cystic ducts and cholelithiasis has seldom been investigated quantitatively. Thus we attempted a retrospective survey on two case series with and without cholelithiasis in a university hospital. A total of 500 patients who underwent endoscopic retrograde cholangiography were reviewed, 250 of whom had cholelithiasis and another 250 no gallstones. They were sampled at random during the period from 1979 through 1993. Parameters including the length, inner diameter and configuration of the cystic duct, and the angle formed by the cystic duct, and the axis of the gallbladder were compared between the groups with or without cholelithiasis. The patients with gallstones has significantly (p<0.001) longer and narrower cystic ducts (a mean of 48mm and 4mm in length and diameter, respectively) than did those without stones (a mean of 28mm and 7mm, respectively). Moreover, patients with gallstones showed a significantly (p<0.001) more acute angle between the gallbladder and the cystic duct than those without (a mean angle of 84° and 119° respectively). The overall frequency of the disfigurements of the cystic duct was significantly higher in the group with gallstones (99%) than in the group without (29%). The results therefore suggested that complex cystic ducts are associated with cholelithiasis.

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To evaluate the role of endoscopic retrograde cholangiography (ERC) before laparoscopic cholecystectomy, we compared the frequency of concomitant common bile duct stones, their clinical outcome, and the frequency of bile duct injury between a group of 128 patients with routine preoperative ERC (group A) and 1010 patients with selective ERC (group B). Overall, 48 patients (4.2%) had duct stones, but the predictive signs were absent in six of them (12.5%). The stones were demonstrated by ERC and removed by sphincterotomy in all 11 patients in group A. Of 37 patients in group B, 22 were diagnosed by selective ERC and underwent endoscopic removal. Of four patients whose stones were found by operative cholangiography, one had immediate open surgery, another passed a stone spontaneously, and the other two underwent postoperative sphincterotomy, which failed in one. The stones were not recognized until pain recurred in the remaining 11 patients. Sphincterotomy was successful in nine patients but failed in the other two. Thus postoperative sphincterotomy failed in 3 of 13 patients (23%), necessitating open surgery. Forty-two patients overall (3.7%) had aberrant biliary tract anatomy, which did not lead to bile duct injury in any of the patients. Morbidity of routine ERC (3.1%) was lower than that of selective ERC (7.4%) (p < 0.05). It should be noted that a certain proportion of duct stones may be missed by selective ERC, necessitating laparotomy when sphincterotomy fails. The routine use of preoperative ERC may be justified at institutions where the expertise is available, at least until laparoscopic lithotomy becomes easy.

Although stenosis is regarded as one of the causes of recurrence of common bile duct stones after endoscopic sphincterotomy, there is a lack of direct evidence. Endoscopic retrograde cholangiography and manometry were performed in 131 patients 2.2–111.1 months (mean 29.9 months) after sphincterotomy, either for follow‐up or at presentation of biliary symptoms. Recurrent stones were found in 33 patients (25%) (recurrent group). The remaining 98 patients (75%) proved not to have recurrence (nonrecurrent group). The common bile duct‐to‐duodenum pressure gradient in the recurrent group (3.3 ± 1.4 mmHg, mean ±SEM) did not differ from that in the nonrecurrent group (2.9 ±1.5 mmHg) (p=0.85). However, as judged by endoscopic findings, we found a significantly elevated frequency of stenosis of the spincter‐otomy orifice in the recurrent group (4 of 33 patients) as compared with the nonrecurrent group (none of 98 patients) (p=0.0035). Recurrence of common bile duct stones appears to correlate with stenosis following sphincterotomy, although manometry does not necessarily indicate the presence of stenosis.