Treatment of Common Bile Duct Stones–is the Role of ERCP Changed in Era of Minimally Invasive Surgery?
Treatment of Common Bile Duct
Stones–is the Role of ERCP Changed in
Era of Minimally Invasive Surgery?
Josip Samardzic1, Ferid Latic1, Darko Kraljik1, Vlatka Pitlovic1, Hrvoje Mrkovic1, Djuro Miskic1,
Azra Latic1, Samir Delibegovic2
Department of surgery, General Hospital “Dr Josip Bencevic”, Slavonski Brod, Croatia1
Department of surgery, University Clinic Center Tuzla, Bosina and Herzegovina2
Professional paper
Summary
In 10-15% of the patients that underwent chole-
cystectomy, common bile duct stones were found
either during the preoperative, intraoperative or
postoperative evaluation. Their treatment tradition-
ally was based on open approach and extraction of
calculi, with development of endoscopic procedures
we have ERCP with endoscopic sphincterotomy, but
due to rapid development of laparoscopic proce-
dures now-days we have other therapeutic options
such as laparoscopic transcystic extraction and
laparoscopic choledohotomy. Methods During the
period between 2007-2009 we treated 168 patients
with common bile duct stones. Age range was 21-78
years,105 female and 63 male patients. We have
performed 47 open explorations, 9 laparoscopic
transcystic exploration, as well as 112 ERCP and ES.
We monitored the rate of success (%), intra- and
postoperative complications. Results: The success
rate of the cases of open exploration was 95%, in 2
Corresponding author: Josip Samardzic. MD. Department of surgery. General hospital “Dr Josip Bencevic”,
Slavonski Brod, Croatia. Tel.:+385 91 334 0415, E-mail: josip.samardzic@gmail.com
1. Introduction
In 0 -15% of the patients that
underwent cholecystectomy, common
bile duct stones were found either
during the preoperative, intraoperative
or postoperative evaluation (1, 2, 3).
A lthough laparoscopic chole-
cystectomy has become the golden
standard in the treatment of the gall-
stone disease, the treatment of common
bile duct stones (CBDS) continues to
raise numerous discussions. De-
velopment of laparoscopic surgery and
improvement of diagnostic procedures
have influenced new approaches to
biliar surgery. Gradual expan-ding of
spectrum of minimally invasive surgical
calculi, with development of endos-
cases postoperative cholangiogram showed concre- copic pocedures we have ERCP with
ment residues that were successfully treated later on
ES (pre-operative, intraoperative,
with ERCP+ES. Out of 9 transcystic LCBDE we have
performed, in 4 cases extraction was successful, 3 postoperative), transcistic stenting
patients underwent conversion into open exploration, a nd sph incterotomy, but due to
and 2 patients were successfully treated with post-
rapid development of laparoscopic
operative ERCP. A total of 69 patients were treated
with ERCP and ES with the 82% success rate of stone
p r o c e d u r e s n o w- d a y s w e h a v e
extraction. Conclusion Even though laparoscopic another therapeutic options such as
and endoscopic procedures have revolutionized laparoscopic transcistic extraction,
treatment of common bile duct stones, the role of
laparoscopic choledochotomy. That is
ERCP is not changed. Treatment in general hospital
settings largely depends on availability of endoscopic why we performed the study to eva-
luate traditional open approach with
and laparoscopic equipment and expertise, and must
be individualized according to methods that are ERCP and laparoscopic transcistic
available. In our settings we have found that best
summary of these demands are achieved by ERCP
extraction (LCBDE) and to find the
best option that can be used in general
and laparoscopic approach.
Key words: ERCP, Choledocholithiasis, Laparoscopic hospital settings.
cholecystectomy.
2. Materials and methods
During the period between 2007-
2009 we treated 168 patients with
common bile duct stones.We included
patients that were admitted for elective
procedures have proven feasibility and
chlolecystectomy as well as other
advantages of laparoscopic approach.
patients admitted with suspicion of
Generally accepted strategy is
common bile duct stones. Age span
treatment of CBDS in all circumstances,
was 21-78 years, 105 female and 63 male
except in selected patients that have
patients. We have performed 47 open
contra ind ications (e.g.ref usa l of
explorations, 9 laparoscopic transcystic
operative or endoscopic treatment
exploration, as well as 112 ERCP and ES.
etc.), when conservative and expecting
We monitored the rate of success (%) of
modality are accepted (1, 4). Diagnostic
these procedures, intra- and postope-
algorithm of CBDS consists of clinical
rativne complications.
aspect, laboratory tests and ultrasound
exam followed by radiological (CT,
3. Results
MRCP), endoscopic (EUS, ERCP) and
The success rate of the cases of
surgical (IOC, IOUS, LCBDE, open
open exploration was 95%, in 2 cases
approach) procedures (2, 3). Treatment
postoperative cholangiogram showed
of CBDS traditionally was based on
concrement residues that were success-
open approach and extraction of
fully treated later on with ERCP+ES.
MED ARH 2010; 64(3) • Professional papers 187
Treatment of Common Bile Duct Stones–is the Role of ERCP Changed in Era of Minimally Invasive Surgery?
Out of 9 transcystic LCBDE we have
performed in 4 cases extraction was
successful, 3 patients underwent con-
version into open exploration, and 2
patients were successfully treated with
postoperative ERCP.
A total of 69 patients were treated
with ERCP and ES (preoperatively and
postope-ratively) with the 82% success
rate of stone extraction (57 successful
extractions). In cases where ERCP and
ES failed we opted for open exploration.
When it comes to ERCP and ES, we
achieved greatest success with cases
of CBDS after cholecystectomy (60%
of patients in ERCP group, totally 42
patients). In any group we have not noti-
ced any intra- and post-operative com-
plications (Table 1).
4. Discussion
The treatment of common bile
duct stones (CBDS) continues to
raise numerous discussions. Open
exploration still remains valuable and
effective method in cases of stones
detected during open cholecystectomy,
or large and impacted stones, or in a
need for biliodigestive by pass and finaly
in cases of failure of other methods. We
give advantage to this method in cases
of portal hypertension, cholangitis with
septic schock or periportal inflamation.
Figure 1. Extraction of concrements with
laparoscopic method using baloon cateter
E RC P a nd endo s copic sphy-
ncterotomy can be performed as
pre op er at ive, i nt r aop er at ive or
postoperative method. In most cases is
used when common bile duct stones are
proven preoperativly, in cases of acute
cholangitis or biliary pancreatitis,or
in patients with high risk of general
anesthesia. This method showed high
efficiency in patients with common
bile duct stones af ter performed
cholecystectomy. Disadvantages of
ERCP include need for endoscopic
equipment and experts, in a fact
that it is a two stage procedure, and
188 MED ARH 2010; 64(3) • Professional papers
Procedure Number of cases
ERCP+ES 69
Open Exploration 47
LCBDE 9 44
Table 1: Results of surgical treatment by laparoscopy
Type of procedure
ERCP+ES
Open Exploration
LCBDE
Table 2: Discussion overview of results of treated patient
for its complications (pancreatitis,
haemorage, secondary cholangitis,
perforation).
Laparoscopic common bile duct
exploration (LCBDE) can be achieved
through trans-cistic approach or
by per form i ng choledochotomy.
Transcystic aproach is less invasive but
has it’s limitations due to anatomical
variations (relation between cisticus
and common bile duct) and by the
size (>6mm) and number of stones.
In such cases method of choice is
laparoscopic choledochotomy and
extraction. Laparoscopic aproach
has all the advantages of minimaly
invasive procedure (less pain, cosmetic
effect, shorter hos-pitalisation) and
is done as one stage procedure, and
is as effective as ERCP. Failure to
extract stones during LCBDE can
result in open extraction in same act.
In our opinion main disadvantages
are prolonged operative time, and lack
of trained personal for this complex
procedure, especialy for laparoscopic
choledochotomy and extraction (5).
Vast number of published papers have
compared efectivness of mentioned
procedures, and debate is still in
progress (Table 2). Open exploration
even though most invasive, still remains
efective method (6, 7). It demands no
aditional procedures and is method
of choice if other methods fail or are
unavailable. Comparison of ERCP+ES
and LCBDE haven’t proven diferences
in efectivness, mortality and morbidity
(4, 6, 7). LCBDE needs less procedures
and has shown shorter hospital stay
than ERCP i ES (4, 6, 8).
Even though laparoscopic and
Rate of success
Definitive treatment
(%)
82 Open exploration
95 ERCP+ES
Open 3, ERCP+ES 2
Advantages Disadvantages
Less invasive
Equipment
Local expertise
Procedure od choice in post-
2 stage procedure
cholecystectomy patients
Complications
Most effective
Most invasive
Universal feasibillity
Equipment
Minimal invasive Local expertise
One stage proedure Anatomic variations
Prolonged OR time
endoscopic procedures have revoluti-
onized treatment of common bile duct
stones, the role of ERCP is not chan-
ged. Treatment in general hospital
settings largelly depends on availability
of endoscopic a nd lapa roscopic
equipement and expertise, so every
treatment must be individualized
according to methods that are available
and which are determined by efficiency,
morbidity, mortality, cost effectivness
and patients preferences. In our settings
we have found that best summary of
these demands are achieved by ERCP
and laparoscopic approach.
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