Various Techniques for the Surgical Treatment of Common Bile Duct Stones: A Meta Review

Hindawi Publishing Corporation Gastroenterology Research and Practice Volume 2009, Article ID 840208, 12 pages doi:10.1155/2009/840208 Review Article Various Techniques for the Surgical Treatment of Common Bile Duct Stones: A Meta Review Abolfazl Shojaiefard,1 Majid Esmaeilzadeh,2 Ali Ghafouri,1 and Arianeb Mehrabi2 1 Department of Surgery, Shariati Hospital, Tehran University of Medical Sciences, Tehran, Iran 2 Department of General, Visceral and Transplantation Surgery, University of Heidelberg, 69120 Heidelberg, Germany Correspondence should be addressed to Arianeb Mehrabi, arianeb Received 23 March 2009; Accepted 25 May 2009 Recommended by Gianfranco D. Alpini Common bile duct stones (CBDSs) may occur in up to 3%–14.7% of all patients for whom cholecystectomy is preformed. Patients presenting with CBDS have symptoms including: biliary colic, jaundice, cholangitis, pancreatitis or may be asymptomatic . It is important to distinguish between primary and secondary stones, because the treatment approach varies. Stones found before, during, and after cholecystectomy had also differing treatments. Different methods have been used for the treatment of CBDS but the suitable therapy depends on conditions such as patient’ satisfaction, number and size of stones, and the surgeons experience in laparoscopy. Endoscopic retrograde cholangiopancreatography with or without endoscopic biliary sphincterotomy, laparoscopic CBD exploration (transcystic or transcholedochal), or laparotomy with CBD exploration (by T-tube, C-tube insertion, or primary closure) are the most commonly used methods managing CBDS. We will review the pathophysiology of CBDS, diagnosis, and different techniques of treatment with especial focus on the various surgical modalities. Copyright © 2009 Abolfazl Shojaiefard et al. This is an open access article distributed under the Creative Commons Attribution License, which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is properly cited. 1. Introduction CBDSs are one of the medical conditions leading to surgical intervention. They may occur in 3%–14.7% of all patients for whom cholecystectomies are preformed [1, 2]. When patients present with CBD, the one important question that should be answered: what is the best modality of treatment under the giving conditions? There are competing technologies and approaches for diagnosing CBDS with regard to diagnostic performance characteristics, technical success, safety, and cost effectiveness. Management of CBDS usually requires two separate teams: the gastroenterologist and the surgical team [3]. One of the main factors in the management is initially the detection of CBDS, before, during, or after cholecystectomy. The main options for treatment are pre- or postoperative ERCP with endoscopic biliary sphincterotomy (EST), laparoscopic or open surgical bile duct clearance. There are other options for the treatment of CBDS such as electrohydraulic lithotripsy (EHL), extracorporeal shockwave lithotripsy (ESWL), dissolving solutions, and laser lithotripsy. It is unlikely that one option will be appropriate for all clinical circumstances in all centers. Variables such as disease status, patient demographics, availability of endoscopic, radiological and surgical expertise, and healthcare economics will all have significant influence on practice [4]. 2. Method A Medline-based search on all published papers (English and German) for CBDS diagnosis and treatment was performed. The search terms used for the review included common duct stones, clinical presentation of CBDS, diagnostic approach of CBDS, MRCP, transabdominal ultrasonography, intraoperative cholangiography, common duct exploration, common bile duct exploration, laparoscopic common bile duct stone endoscopic sphincterotomy, trans-cystic, and ductal approach. This paper serves to delineate the current relevant concepts in the varying treatments of patients that present with CBDS. We also present a possible algorithm for the treatment of CBDS (Figure 1). 2 Gastroenterology Research and Practice Symptomatic choledocholithiasis Bilirubin ≥ 30 μmol/l, dilated CBD, colic pain Bilirubin < 30 μmol/l, NL or dilated CBD, elevated LFTs Cholangitis or severe pancreatitis ERCP/EST or LC with IOC ERCP Successful Successful Failure LC Failure LC LC + LCD LC + TC-CBDE PTC LC + TC-CBDE Failure Failure or or Post-Op ERCP LCD Post ERCP OCBDE with IOC Figure 1: Algorithm for management of common bile duct stones. LC: Laparoscopic cholecystectomy, LCD: Laparoscopic choledochotomy, PTC: Percutaneous transhepatic catheter drainage, TC-CBDE: Transcystic common bile duct exploration, OCBDE: Open common bile duct exploration, IOC: Intraoperative cholangiogram. 3. Pathogenesis and Clinical Manifestation CBDS can be caused either by primary bile duct stones that originate in the bile duct or by secondary bile duct stones that have descended from the gallbladder [6]. In the primary stones, bilirubin is dominant component and is associated with biliary stasis and infection. In secondary stones, cholesterol is dominant component. It is therefore important to distinguish between primary and secondary stones. Cholecystectomy and choledocholithotomy are sufficient in the management of secondary stones, while the presence of primary stones often necessitates a more complex drainage procedure to prevent recurrence [7, 8]. Table 1 shows the types of bile duct stones [5]. In addition, cholecystectomy at a young age leads to CBD dilatation and is another acquired risk factor for CBD stones [9]. The symptoms and signs of CBDS are highly variable and can range from patients being completely asymptomatic, to complications such as cholangitis or pancreatitis [10]. Literature describes the Prevalence of asymptomatic CBDS between 5.2% and 12% [11]. A common presentation of CBDS is the biliary colic. Pain is often situated in the right hypochondrium or epigastrium and can last from 30 minutes to several hours, with associated symptoms such as nausea and vomiting [10]. Other common symptoms include pale stools and dark-colored urine, which can be elicited in the patient history by a thorough review of systems [12]. Two serious complications of CBDS are cholangitis and gallstone pancreatitis. Acute obstructive cholangitis (AOC) is a life-threatening complication caused by an infection of the biliary ductal system secondary to biliary obstruction. Cultures are most often positive for E. coli, and the infection clears in more than 75% of cases with antibiotic treatment [13]. In cholangitis, the classic symptoms of Charcot’s triad may be encountered, and the less common Reynold’s pentad adds to the diagnosis [7, 13]. Despite the advancement in treatment, AOC still carries a mortality rate of 10–20% [14]. It remained unclear for a long time why some gallstone patients suffer from pancreatitis, while others are spared from this potentially lethal c (...truncated)