Page 12 - World Journal of Laparoscopic Surgery

REVIEW ARTICLE Practical Considerations for Common Duct Stone Clearance

Practical Considerations for Common Duct

Stone Clearance

Dennis L Sta Ana
Department of Surgery, Marikina Valley Medical Center, Sumulong ave, Marikina City-1800, Philippines

Abstract
Patients undergoing cholecystectomy have a 10 to 18% chance of common duct stone (CDS) being discovered during the procedure.
With the advent of laparoscopy the generally successful open common bile duct exploration for the treatment of common duct stone has
been largely replaced by endoscopic means. Lately however, endoscopic clearance is being challenged by a single stage laparoscopic
common duct exploration. No clear consensus has been developed to delineate specific practice guidelines for each procedure. Even
so, different variables such as patient variables, institutional limitations and technical considerations make the choice of the appropriate
procedure a lot more confusing. It is the aim of this article review to find out practical options for the surgeons on the basis of established
parameters for safe surgery as well circumstantial parameters that may be variably present in different hospital settings.The search
strategy was to review literatures, abstracts, electronic databases, and bibliographies published from year 1999 until 2008 using
different medical search engines. Results of this review showed two RCTs (n 378) comparing preoperative endoscopic clearance vs
laparoscopic stone clearance and two smaller RCTs (n 166) which compared single stage laparoscopic stone clearance vs delayed
endoscopic clearance. There was shorter length of stay in the laparoscopy arm in both studies but stone clearance rate, mortality and
morbidity were not significantly different for all studies. Literatures that dealt with circumstantial parameters such as patient variables,
institutional limitations and technical expertise, all showed positive significance for these parameters in predicting the success or failure
of a procedure for common duct clearance.
Keywords: Common duct stones, cholecystitis, choledocholithiasis, ERCP, complications, laparoscopic choledochotomy, endoscopic
surgery.

OBJECTIVES ES, (4) Laparoscopic cholecystectomy with common duct
clearance via transcystic route (LTCCBDE) or through a
The objectives of this review were to compare available data on choledochotomy (LCBDE). Variables commonly used in the
four of the common procedures for CDS clearance. Procedures formulation of treatment strategy were chosen for analysis. This
included were. (1) Open CBDE, (2) Preoperative ERCP, (3) included articles dealing with institutional limitation, technical
Postoperative ERCP, and (4) Laparoscopic common bile duct expertise and patient factors. These variables were then studied
clearance (LCBDC) based on success rate, mortality, morbidity, for its possible contribution in the choice of treatment modality.
length of hospital stay, and cost. This review also aimed to find
out how circumstantial parameters such as patient variable, INTRODUCTION
institutional limitation and technical consideration would affect
the decision making process for the treatment of CDS. NIH consensus of 1993 replaced open cholecystectomy with
Laparoscopic cholecystectomy as the procedure of choice for
MATERIAL AND METHODS cholecystolithiasis. Gallstone, even if it is asymptomatic, has a
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10-50% chance of complication within 20 years. In patients
A systematic literature search for relevant articles, abstracts, who undergo cholecystectomy, 18% will be found to have
bibliographies and electronic data base using search engines choledocolithiasis. With the dawning of the laparoscopic
3,4
such as Google, Springerlink, Highwire Press, and Medline. era, Endoscopic retrograde cholangio pancreatography (ERCP)
Thirty articles were chosen of which 4 randomised controlled became popular in common duct stone (CDS) removal. In the
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trials and one systematic review were. beginning, it was a choice between open common bile duct
Accepted methods of treatment for common bile duct stone exploration (CBDE) and endoscopic stone clearance (ERCP/
were evaluated for its outcome measures such as mortality, ES) for CDS. With technical advances in laparoscopic removal
morbidity, success rate, duration of hospital stay and cost. No of stone and the improvement in skills among laparoscopic
attempt was made to install one procedure as the best procedure surgeons, more and more used the single stage method of
for all types of scenario. Findings are presented based on removing the CDS. It has now become important to compare
available data gathered from the literature search. laparoscopic and endoscopic approaches in the removal of
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Accepted methods of treatment for common duct stones common duct stones so that guidelines may be set. At present,
are: (1) Open CBDE, (2) Preoperative, (3) Postoperative ERCP/ there are a lot of controversies in the management of CDS. To
World Journal of Laparoscopic Surgery, September-December 2009;2(3):11-14 11