Bile duct stones in the laparoscopic era. Is preoperative sphincterotomy necessary?
E. H. Phillips, M. Liberman, B. J. Carroll, M. J. Fallas, R. J. Rosenthal and J. R. Hiatt
Department of Surgery, Cedars-Sinai Research Institute, Cedars-Sinai Medical Center, Los Angeles, Calif., USA.
OBJECTIVE: To evaluate treatments for common bile duct stones (CBDS).
DESIGN: Retrospective review of authors' case series. SETTING: Large
private metropolitan teaching hospital. PATIENTS: All patients with CBDS (N
= 145) from a series of 1231 patients who underwent laparoscopic
cholecystectomy, 99% with intraoperative fluorocholangiography.
INTERVENTIONS: Treatments for CBDS included one or more of the following:
laparoscopic transcystic duct exploration (n = 123), laparoscopic
choledochotomy (n = 10), open choledochotomy (n = 7), preoperative
endoscopic sphincterotomy (ES) (n = 9), intraoperative ES (n = 2),
post-operative ES (n = 11), or observation (n = 10). MAIN OUTCOME MEASURES:
Success of various interventions for CBDS, morbidity and mortality,
frequency of retained stones, operative time, and length of postoperative
hospitalization. RESULTS: Laparoscopic transcystic duct exploration was
successful in 91% of attempts and resulted in the shortest postoperative
stay (3.4 days), least morbidity (5%), and fewest retained stones (5%).
Endoscopic sphincterotomy was successful in 56% of preoperative attempts,
50% of intraoperative attempts, and 91% of postoperative attempts. There
were no reoperations and one death. CONCLUSIONS: For patients requiring
cholecystectomy, laparoscopic transcystic duct exploration is safe and
effective, treats CBDS in one session, and if unsuccessful still allows for
open choledochotomy or postoperative ES. Preoperative endoscopic retrograde
cholangiography and ES should be reserved for patients with serious illness
or possible malignant disease.
