Managing Common Bile Duct Stones
Common duct stones (choledocholithiasis) pose a high risk for complications and nearly always warrant treatment. There are various options available. It is not clear yet which one is optimal:
- In the past, when common bile duct stones were suspected, the approach was open surgery (open cholecystectomy) and surgical exploration of the common bile duct. This required a wide abdominal incision.
- Endoscopic retrograde cholangiopancreatography (ERCP) with endoscopic sphincterotomy (ES) is now the most frequently used procedures for detecting and managing common duct stones. The procedure involves the use of an endoscope (a flexible telescope containing a miniature camera and other instruments), which is passed down the throat to the bile duct entrance.
- Laparoscopic cholecystectomy also is increasingly being used for detection and removal of common duct stones. This is an approach through the abdomen but uses small incisions. In such cases, it is used in combination with ultrasound or a cholangiogram (an imaging technique in which a dye is injected into the bile duct and x-rays are used to view any stones.)
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Experts are currently debating the choice between laparoscopy (which is an abdominal approach) and ERCP (in which the approach uses a tube down the throat). Many surgeons believe that laparoscopy is becoming safe and effective and should be the first choice. Still, laparoscopy for common duct stones should be performed only by surgeons experienced in this new and demanding technique.
How to Select Specific Common Bile Duct Stone Procedures |
Endoscopic Retrograde Cholangiopancreatography (ERCP)
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Laparoscopic Common Bile Duct Exploration
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Open Common Bile Duct Exploration (Choledocholithotomy)
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- Before gallbladder surgeries when there is strong suspicion that common bile duct stones are present.
- After gallbladder surgeries in which the surgeon detects stones in the common bile duct (only if there are experts in ERCP and equipment is available).
- For patients with gallstone cholangitis (serious infection in the common bile duct). In such cases urgent ERCP plus antibiotics is required.
- When acute pancreatitis is caused by gallstones. In such cases urgent ERCP plus antibiotics is required. (The use of ERCP compared to conservative treatment has been controversial. One study reported that only patients who had infection and persistent obstruction in the ducts benefited from urgent ERCP intervention. In a 2000 analysis of four studies, however, ERCP significantly improved survival rates and reduced complications.)
| - As an alternative to ERCP before gallbladder surgeries when there is high suspicion of common bile duct stones. (Should be performed only in centers with expertise in this procedure, where it may actually be preferable to ERCP.)
- During gallbladder surgeries when common duct stones are detected or highly suspected. (Only for centers with expertise in this procedure.)
| - During or after some gallbladder operations when stones are detected. If procedure is laparoscopy, surgeon may convert to open procedure. Less often used now.
- When ERCP or laparoscopic procedures are not available.
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