Options and Strategies for the Management of Choledocholithiasis

Abstract

The introduction of laparoscopic techniques for the management of biliary stone disease has expanded the therapeutic choices for surgeons confronted with choledocholithiasis. As new strategies emerge, the treatment of cholelithiasis and choledocholithiasis remains controversial. This paper discusses the options available for the treatment of common bile duct stones. Diagnostic and therapeutic algorithms are proposed. The treatment of these patients must be individualized, taking into consideration the condition of the patient, associated diseases, secondary complications of the gallstones, and the surgical expertise and resources of the institution.

Common bile duct stones — their presentation, diagnosis and management

“…Since most CBD stones are situated in this portion, this procedure appears to be inferior to IOC [9].…”

“…In patients below 60 years CBD stones occur in 8-15% while in those above 60 they are seen in 15-60% [9]. In patients with acute cholecystitis they are seen in 18% of patients [9].…”

“…In the diagnosis of CBD stones, US exhibits poor test performance at detecting CBD stones with sensitivities in the range of 25-58% and specifi cities of 68-91% [48]. A normal US result in conjunction with normal total bilirubin and alkaline phosphatase levels has been shown to have an excellent negative predictive value for choledocholithiasis, approaching 95% [7][8][9][10]. When used in tandem with 5 biochemical parameters (bilirubin, SGOT, SGPT, alkaline phosphatase, GGT, it achieves a predictive accuracy as high as 95%, if, any two biochemical parameters are positive [7][8][9][10].…”

“…A normal US result in conjunction with normal total bilirubin and alkaline phosphatase levels has been shown to have an excellent negative predictive value for choledocholithiasis, approaching 95% [7][8][9][10]. When used in tandem with 5 biochemical parameters (bilirubin, SGOT, SGPT, alkaline phosphatase, GGT, it achieves a predictive accuracy as high as 95%, if, any two biochemical parameters are positive [7][8][9][10]. Interpreting this data if there is a high suspicion of stone based on clinical and biochemical parameters, ultrasound would be capable of confi rming a CBD stone at a statistically satisfactory level .…”

“…In the absence of a T-tube tract, a transhepatic approach using PTC can be used, if ERCP is not possible and surgery is contraindicated. While giving good results, it requires considerable skill on the part of the radiologist and has a success rate from 88-97% and a morbidity rate of 5-10% [9]. Larger stones can be fragmented and then extracted.…”