Diagnosis and management of choledocholithiasis in the golden age of imaging, endoscopy and laparoscopy

Abstract

Biliary lithiasis is an endemic condition in both Western and Eastern countries, in some studies affecting 20% of the general population. In up to 20% of cases, gallbladder stones are associated with common bile duct stones (CBDS), which are asymptomatic in up to one half of cases. Despite the wide variety of examinations and techniques available nowadays, two main open issues remain without a clear answer: how to cost-effectively diagnose CBDS and, when they are finally found, how to deal with them. CBDS diagnosis and management has radically changed over the last 30 years, following the dramatic diffusion of imaging, including endoscopic ultrasound (EUS) and magnetic resonance cholangiography (MRC), endoscopy and laparoscopy. Since accuracy, invasiveness, potential therapeutic use and cost-effectiveness of imaging techniques used to identify CBDS increase together in a parallel way, the concept of "risk of carrying CBDS" has become pivotal to identifying the most appropriate management of a specific patient in order to avoid the risk of "under-studying" by poor diagnostic work up or "over-studying" by excessively invasive examinations. The risk of carrying CBDS is deduced by symptoms, liver/pancreas serology and ultrasound. "Low risk" patients do not require further examination before laparoscopic cholecystectomy. Two main "philosophical approaches" face each other for patients with an "intermediate to high risk" of carrying CBDS: on one hand, the "laparoscopy-first" approach, which mainly relies on intraoperative cholangiography for diagnosis and laparoscopic common bile duct exploration for treatment, and, on the other hand, the "endoscopy-first" attitude, variously referring to MRC, EUS and/or endoscopic retrograde cholangiography for diagnosis and endoscopic sphincterotomy for management. Concerning CBDS diagnosis, intraoperative cholangiography, EUS and MRC are reported to have similar results. Regarding management, the recent literature seems to show better short and long term outcome of surgery in terms of retained stones and need for further procedures. Nevertheless, open surgery is invasive, whereas the laparoscopic common bile duct clearance is time consuming, technically demanding and involves dedicated instruments. Thus, although no consensus has been achieved and CBDS management seems more conditioned by the availability of instrumentation, personnel and skills than cost-effectiveness, endoscopic treatment is largely preferred worldwide.

Eleven years of primary closure of common bile duct after choledochotomy for choledocholithiasis

“…The strategy to be adopted will largely depend on local availability of surgical and endoscopic skills. Concerning CBD stones diagnosis, IOC, MRC and EUS are reported to have similar results [21].…”

“…Low-risk patients do not require further examination before laparoscopic cholecystectomy. Those with a moderate or high risk require further diagnostic tests [20][21][22].…”

Role of MRCP in The Assessment of Patients Undergoing Cholecystectomy

“…Although common bile duct (CBD) stones may be silent but it can often lead to biliary colic, cholangitis, jaundice, or pancreatitis. There are various techniques available for the visualization of biliary tree Costi et al (9) reported that ERCP after having been widely used for CBD stones diagnosis in the late eighties/nineties. ERCP is nowadays being progressively abandoned as a diagnostic tool for patients with moderate to intermediate risk of carrying CBD stones, as most cholangiograms result as being normal and ERCP is not costeffective.…”

Evaluación costo efectividad del tratamiento en un solo tiempo de colelitiasis con coledocolitiasis mediante el uso de laparoscopia y su asociación con el abordaje laparo-endoscópico

“…Toda conducta encaminada al tratamiento de complicaciones, incrementa el costo asistencial y social (SANTO et al, 2012;BARRETO et al, 214;INEC. 2011;COSTI et al, 2014;GRINIATSOS et al, 2016).…”