Bile duct clearance, endoscopic or laparoscopic?

Abstract

Endoscopic sphincterotomy (ES) has become the gold standard nonoperative modality for the removal of common bile duct (CBD) stones. Morbidity is 2%-10%, and mortality less than 2%. Immediate complications include bleeding, cholangitis, pancreatitis, and duodenal perforation, but many of these can be prevented by using various tools, including an alternating coagulating and cutting diathermy unit, routine biliary stenting, frequent use of guide-wires to avoid precutting, and mechanical lithotripsy. Long-term results have shown that the stone recurrence rate reaches 15%, probably due to a strong recurrent tendency inherent to bilirubinate stones. Choice of the appropriate lithotomy modality is of paramount importance to reduce invasiveness. ES is the choice for recurrent or residual stones and for choledocholithiasis alone. Acalculous gallbladders left in place carry no risk of acute cholecystitis. In patients with cholecystocholedocholithiasis, CBD stones should be removed via the cystic duct or by choledochotomy during laparoscopic cholecystectomy, not to preserve the sphincter of Oddi but to reduce the interventional burden. Safety and safeguards of papillary balloon dilation must still be investigated in a limited number of institutions. Marked progress in lithotomy/lithotripsy procedures has almost obviated the need for laparotomy. Patients with CBD stones benefit from the less invasive and more efficient modalities of transpapillary, percutaneous, and laparoscopic lithotomy.

Nationwide study of the treatment of common bile duct stones in Sweden between 1965 and 2009

“…Escarce and colleagues25 reported a 90‐day mortality rate of about 4 per cent after open surgery in a cohort of elderly patients. The postprocedure mortality rate after ERCP ranges from 0 to 6 per cent in non‐population‐based studies26–29, and rates of 0–0·6 per cent have been reported after laparoscopic treatment11, 30. The 30‐ and 90‐day mortality rates for open exploration and ERCP in the present study are similar to these previous results.…”

Stone clearance and risk factors for failure in laparoscopic transcystic exploration of the common bile duct

“…Pancreatitis, cholangitis, perforation of the duodenum, and bleeding are reported at an incidence of 3-23% and mortality of 0-6% [2,[18][19][20][21]. If preoperative ERC is chosen there is a risk of performing a number of unnecessary potentially dangerous procedures [22,23].…”

“…About 10-15% of the patients develop late complications as stone recurrence and cholangitis [19,20,24]. There have been reports that ES may increase the risk of developing cholangiocarcinoma, possibly by long-term contamination of bacteria in the bile ducts [18,24,25] and many patients with CBD stones are young with a long life expectancy.…”

Failure of sequential biliary stenting for unsuccessful common bile duct stone removal

“…The majority (80%-90%) of simple CBD stones, specifically those that are < 1 cm, are removed by ERC via endoscopic sphincterotomy by using a basket or balloon catheter [2,3] . However, from references [4][5][6][7][8][9][10][11][12][13][14][15] , we know that approximately 10%-15% of patients have bile duct stones that cannot be removed using standard techniques. These stones are generally larger than 1-1.5 cm, impacted, located proximal to strictures, or associated with the duodenal diverticulum, and are frequently successfully removed by mechanical lithotripsy or large balloon sphincteroplasty [16] .…”