Pre- or post-operative endoscopic retrograde cholangiopancreatography for bile duct clearance in patients undergoing cholecystectomy for gallstones offers no apparent advantage over surgical exploration
Between 10% to 18% of patients undergoing cholecystectomy for gallstones have common bile duct stones. Treatment options for these stones include pre- or post-operative endoscopy (endoscopic retrograde cholangiopancreatography), open surgery, or laparoscopic bile duct exploration. In the era of open cholecystectomy, open bile duct surgery was significantly superior to endoscopic retrograde cholangiopancreatography in achieving common bile duct stone clearance. A trend towards decreased mortality was also surprisingly seen in the surgical arm. Laparoscopic cholecystectomy with simultaneous laparoscopic bile duct exploration seem to be as safe and as efficient as endoscopic retrograde cholangiopancreatography, and avoid an extra procedure.
Incidence of Bile Duct Stones in Cholecystectomy Patients
About half of bile duct stones found in patients with normal preoperative abdominal ultrasound are either false-positive or pass spontaneously.
Intraoperative cholangiography (IOC) identifies bile duct stones (BDS) that were not predicted by preoperative imaging in as many as 10% of patients, but only 2% to 3% of these patients develop symptoms. Therefore, it is likely that some stones identified during IOC are actually air bubbles (false-positive studies), spontaneously passed out of the biliary tree, or that persist without causing symptoms. To examine the incidence and natural history of such stones, researchers in Ireland prospectively evaluated 999 patients with symptomatic gallstones who were undergoing laparoscopic cholecystectomy with IOC; none had jaundice, biliary dilation, or BDS on abdominal ultrasound. In patients with filling defects identified on IOC, a fine-bore cholangiogram catheter was left in the cystic duct for repeat cholangiography at 48 hours and 6 weeks.
IOC was successful in 962 patients (96%). Of 46 patients (4.8%) with filling defects on IOC, 12 (26%) had normal cholangiograms at 48 hours (classified as false-positive IOC), and 12 (26%) had normal cholangiograms at 6 weeks (spontaneous stone passage). No patient developed complications from stone passage, and only 2 patients reported a single episode of pain. Twenty of the remaining 22 patients with filling defects had their stones removed endoscopically. The other 2 patients were managed expectantly and remained asymptomatic at 5 years.
Multivariate analysis indicated that the presence of BDS was significantly correlated with elevated alkaline phosphatase levels and patient age, but neither factor predicted spontaneous stone passage. Similarly, the diameter of the bile duct, number of stones, and size of the stone did not predict spontaneous passage of stones.
Comment: Bile duct stones occur in 3.5% of patients with normal preoperative abdominal ultrasound, but about half of these patients either have false-positive IOCs or pass the stones spontaneously. Thus, 50% of patients would undergo unnecessary invasive interventions based on IOC findings alone. An alternative strategy is expectant management (magnetic resonance cholangiopancreatography or endoscopic ultrasound performed at 6 weeks and endoscopic retrograde cholangiopancreatography for identified stones). Because IOC did not influence management in more than 95% of patients, selective IOC may be more appropriate than routine IOC.
— Stuart Sherman, MD
Published in Journal Watch Gastroenterology February 18, 2004
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