Gallstones and Gallbladder Disease - Managing Common Bile Duct Stones

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Pancreatitis (inflammation of the pancreas) occurs in 3% to 9% of cases and can be very serious. Younger adults are at higher risk than the elderly. The risk is also higher with more complex procedures. The drugs somatostatin or gabexate are sometimes used to reduce the risk. Gabexate appears to be more effective, although studies are mixed on whether its benefits are significant, particularly with short-term administration. (Evidence suggests that somatostatin does not reduce this risk.)

Postoperative infection. Antibiotics may be given before the procedure to prevent infection, although one study reported that they had little benefit.

Bleeding occurs in 2% of cases. There is an increased risk in patients taking anti-clotting drugs and those who have cholangitis. This complication is treated by flushing the area with epinephrine.

Perforations (rare).

Long-term complications include stone recurrence and abscesses.

ERCP and ES are difficult procedures and patients must be certain their doctor and the medical center are experienced with them. The surgeon should have performed at least 180 ERCPs. Under such circumstances, ERCP can usually be performed successfully even in critically ill patients on mechanical ventilators.

ERCP and Gallbladder Removal (Cholecystectomy). ERCP is often performed after gallstones in the common duct are discovered during cholecystectomy (removal of the gallbladder).

In some cases, stones in the gallbladder are detected during ERCP. In such cases laparoscopic cholecystectomy is usually warranted. There is some debate about whether the gallbladder should be removed in such cases at the same time as ERCP or if patients should wait. A 2002 study suggested that immediate gallbladder removal is preferred, since the risk for recurring symptoms is very high.

Laparoscopic Exploration and Cholangiography

Surgeons are now increasingly using laparoscopy plus an imaging technique called cholangiography instead of ERCP when common duct stones are suspected. The laparoscopic procedure for common duct stones should be performed only in centers where there is expertise. It generally proceeds as follows:

The initial approach is the same as with laparoscopic cholecystectomy. Small incisions, one or two 10 to 12 mm (around half an inch) and three 5 mm (.20 inches), are made in the abdomen.

A tiny opening is made in the cystic duct that connects the gallbladder to the bile duct, and a thin tube is introduced to perform a cholangiogram. (In this procedure, a dye is administered to reveal the stone's location on x-rays.)

The procedure is typically used in combination with cholangiography, an imaging technique in which a dye is injected into the bile duct and x-rays are used to view any stones. Cholangiography reduces the risk for injury in the common duct.

If stones are identified, the surgeon inserts a tube with an inflatable balloon that is used to widen the duct.

Stones are usually retrieved or withdrawn from the duct either with the use of a balloon or with a tiny basket.

If laparoscopy is unsuccessful, then ERCP or open surgery is performed.