Introduction: Management of common bile duct stones (CBDS) in patients with borderline CBD presents a surgical challenge. The aim of this study was to compare conservative treatment with endoscopic stone extraction for the treatment of borderline CBD with stones. Patients and Methods: This prospective randomized controlled trial includes patients with CBDS in borderline CBD (CBD <10 mm) associated with gallbladder stones who were treated with conservative treatment or endoscopic stone extraction followed by laparoscopic cholecystectomy (LC) and intraoperative cholangiogram (IOC). The primary outcome was successful CBD clearance. The secondary outcomes were the overall complications, cost, and hospital stay. Results: LC and IOC revealed complete clearance of CBDS in 48 (96%) cases in the endoscopic retrograde cholangiopancreatography (ERCP) group (52% of patients by ERCP, and 44% of patient passed the stone spontaneously), and in the remaining two patients, the CBDS was removed by transcystic expl...

Management and Outcome of Borderline Common Bile Duct with Stones: A Prospective Randomized Study

Introduction: Concomitant cholelithiasis and choledocholithiasis are commonly managed in two stage procedure, endoscopic management of common bile duct stone followed by laparoscopic cholecystectomy in different time and setting. We perform these two procedures in same sitting in operating room set up. We evaluated the procedure in terms of outcome, feasibility and complications.
Methods: Prospective cross-sectional study carried out since April 2013 to August 2016 in all patients who had undergone single stage endoscopic and laparoscopic management of concomitant cholelithiasis and choledocholithiasis. Patientâ€™s demography, procedural time for different procedure and procedure in total and post-operative complications were recorded and analyzed with suitable statistical methods.
Results: Out of 50 cases enrolled, 2 patients were converted to open. Out of 48 patients, 3 needed re-attempt for completion. Majority were female 36 (72%), mean age was 39.48years. Mean common bile duct diameter and mean stone size was 11.43Â±2.63 cm and 7.99Â±2.01cm, respectively. Mean of total procedural time was 90.93Â± 33.68 minutes. In most of the cases, laparoscopic cholecystectomy performed first followed by endoscopic method (66.7%). Total procedural time was less in the patients who underwent laparoscopy first in comparison to endoscopy first. Clinically significant complications like cholangitis, pancreatitis and duodenal perforation occurred in 7 patients. Out of 4 patients who developed pancreatitis, one had severe acute pancreatitis requiring prolonged hospitalization.
Conclusion: Single stage management of common bile duct and gall bladder stone by laparoscopic and endoscopic method is feasible in our setup with acceptable results. Endoscopic treatment of common bile duct stone if performed first, is associated with longer procedural time.
Keywords: choledocholithiasis; cholelithiasis; endoscopic retrograde cholangiopancreatography; laparoscopic cholecystectomy.

Single Stage Management of Concomitant Cholelithiasis and Choledocholithiasis.

Cholelithiasis is a kind of common and multiple diseases. In recent years, traditional laparotomy has been challenged by a minimally invasive surgery. Through literature review, the therapeutic method, effect, and complications of minimally invasive treatment of intrahepatic and extrahepatic bile duct stones by combining our practical experience were summarized as follows. (1) For intrahepatic bile duct stones, the operation may be selected by laparoscopic liver resection, laparoscopic common bile duct exploration (LCBDE), or percutaneous transhepatic cholangioscopy. (2) For concomitant gallstones and common bile duct stones, the surgical approach can be selected as follows: laparoscopic cholecystectomy (LC) combined with endoscopic sphincterotomy (EST) or endoscopic papillary balloon dilatation, LC plus laparoscopic transcystic common bile duct exploration, LC plus LCBDE, and T-tube drainage or primary suture. (3) For concomitant intrahepatic and extrahepatic bile duct stones, laparoscopic liver resection, choledochoscopy through the hepatic duct orifice on the hepatectomy cross section, LCBDE, EST, and percutaneous transhepatic cholangioscopic lithotripsy could be used. According to the abovementioned principle, the minimally invasive treatment approach combined with the surgical technique and equipment condition will be significant in improving the therapeutic effect and avoiding the postoperative complications or hidden dangers of intrahepatic and extrahepatic bile duct stones.

Strategies of minimally invasive treatment for intrahepatic and extrahepatic bile duct stones.

In the era of laparoscopic surgery, the best approach for common bile duct (CBD) stones remains a matter of debate. When CBD exploration was performed by laparotomy, prospective randomized trials did not show the superiority of preoperative endoscopic sphincterotomy (ES) over CBD surgery for stones.1,2 The advent of laparoscopic surgery led to a dramatic change in the approach of CBD stones treatment. Indeed, because of an obvious lack of expertise in laparoscopic surgery, surgeons elected to detect and treat preoperatively CBD stones by ES since they considered laparoscopic CBD exploration as an unduly, complex, and demanding procedure. It is worth mentioning that this approach requires several sessions of anesthesia and cumulates the risk of ES and laparoscopic cholecystectomy. In addition, it increases the cost.3,4 About 15 years after the introduction of laparoscopic cholecystectomy, one has to wonder whether or not this policy should be still applied. Indeed, in patients fit for surgery, laparoscopic CBD stones extraction seems to be superior to the association of ES and laparoscopic cholecystectomy.5 The reported incidence of CBD stones found during laparoscopic cholecystectomy ranges from 3 to 10%.6−8 It is unclear whether an asymptomatic choledocholithiasis requires treatment. Furthermore, it is well established that small stonesmay pass through the ampulla of Vater.9 Moreover, it is not clear what stone size precludes transpapillary migration into the duodenum nor which criteria will predict complications of pancreatitis or cholangitis if CBD stones are not treated. Therefore, it is generally recommended to treat CBD stones whenever detected. Theoretically, CBD stones can be treated with or without cholecystectomy. Moreover, if cholecystectomy is performed this could be done before, during or after CBD stones extraction. The purpose of this chapter is to try to clarify these different points.

https://www.springer.com/cda/content/document/cda_downloaddocument/9780387285481-c2.pdf?SGWID=0-0-45-326595-p73123448

Management of common bile duct stones in the era of laparoscopic surgery.

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Management of common bile duct stones in the era of laparoscopic surgery.