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cbd stone management

ESGE recommends endoscopic placement of a temporary biliary plastic stent in patients with irretrievable biliary stones that warrant biliary drainage.
Strong recommendation, moderate quality of evidence.

ESGE recommends offering stone extraction to all patients with common bile duct stones, symptomatic or not, who are fit enough to tolerate the intervention.
Strong recommendation, low quality evidence.

ESGE recommends the use of cholangioscopy-assisted intraluminal lithotripsy (electrohydraulic or laser) as an effective and safe treatment of difficult bile duct stones.
Strong recommendation, moderate quality evidence.

Main recommendations

ESGE recommends endoscopic ultrasonography or magnetic resonance cholangiopancreatography to diagnose common bile duct stones in patients with persistent clinical suspicion but insufficient evidence of stones on abdominal ultrasonography.
Strong recommendation, moderate quality evidence.

Authors: Gianpiero Manes, Gregorios Paspatis, Lars Aabakken, Andrea Anderloni, Marianna Arvanitakis, Philippe Ah-Soune, Marc Barthet, Dirk Domagk, Jean-Marc Dumonceau, Jean-Francois Gigot, Istvan Hritz, George Karamanolis, Andrea Laghi, Alberto Mariani, Konstantina Paraskeva, Jürgen Pohl, Thierry Ponchon, Fredrik Swahn, Rinze W. F. ter Steege, Andrea Tringali, Antonios Vezakis, Earl J. Williams, Jeanin E. van Hooft

ESGE recommends the following timing for biliary drainage, preferably endoscopic, in patients with acute cholangitis, classified according to the 2018 revision of the Tokyo Guidelines:
– severe, as soon as possible and within 12 hours for patients with septic shock
– moderate, within 48 – 72 hours
– mild, elective.
Strong recommendation, low quality evidence.

ESGE recommends liver function tests and abdominal ultrasonography as the initial diagnostic steps for suspected common bile duct stones. Combining these tests defines the probability of having common bile duct stones.
Strong recommendation, moderate quality evidence.

Decision making is easier when stones are discovered intraoperatively. The availed options are; (a) total laparoscopic clearance, (b) combined laparoendoscopic treatment, (c) conversion to open CBD exploration, and (d) post cholecystectomy ERCP.

Literature search was performed using online search engines, Google, Pubmed, the online Springer link library and the Cochrane Database Systematic Review. Textbooks of gastrointestinal surgery and laparoscopy were also reviewed. Review articles, prospective and retrospective studies which detailed or compared the various treatment strategies for CBD stones were selected and analyzed. Case reports were not reviewed for the article.

Chander et al. [13] operated on 150 patients with documented CBD stones. Of these, 4 patients underwent transcystic exploration of CBD and 146 patients had their CBD stones removed through the transcholedochal route. There were 34 men and 116 women patients with age ranging from 15 to 72 years. The mean size of the CBD on ultrasound was 11.7 ± 3.7 mm and on MRCP 13.8 ± 4.7 mm. The number of stones extracted varied from 1 to 70 and the size of the extracted stones from 5 to 30 mm. The average duration of surgery was 139.9 ± 26.3 min and the mean intraoperative blood loss was 103.4 ± 85.9 ml. There were 6 conversions to open procedures, 1 postoperative death (0.7 %), and 23 patients (15 %) had nonfatal postoperative complications. Three patients had retained stones (2 %) and one developed recurrent stone (0.7 %). In their opinion LCBDE when performed by an experienced surgeon results in no additional morbidity or mortality as compared to open surgery, with excellent success rates (98 % in this series), and thus specially benefits the subgroup of patients with multiple, large, impacted stones in a dilated CBD who were traditionally subjected to open exploration.

The preoperative evaluation for CBD stones should include a careful history, biochemical tests and abdominal ultrasonography. It seems reasonable to avoid further diagnostic preoperative investigations and routine intraoperative cholangiography in patients with absence of jaundice, normal liver function tests, and ultrasonographic evidence of a normal biliary tree (CBD diameter <9 mm) even in the presence of a recent acute Cholecystitis [11].

Stones Discovered Intraoperatively

It is desirable that all those and only those patients with choledocholithiasis should undergo CBD exploration at cholecystectomy. CBD should be imaged if there is intraoperative doubt about choledocholithiasis. This can be achieved by radiographic intraoperative cholangiography (IOC) via the transcystic approach or intracorporeal laparoscopic ultrasonography (LUS). In experienced hands, LUS seems to be as accurate as cholangiography for diagnosis of choledocholithiasis, but can be performed more rapidly. Li et al. in 2009 have shown that LUS is more sensitive than IOC for detecting stones but IOC is better for delineating the anatomy. Both these techniques should be viewed as complementary method to maximise the intraoperative detection of occult CBD stones [12].

When CBD stones are discovered intraoperatively, a surgeon has to decide whether to go ahead with single stage laparoscopic management or complete the cholecystectomy followed by sequential endoscopic clearance of CBD. Two prospective randomized studies have evaluated the merits of immediate versus delayed treatment for bile duct stones. Rhodes et al. [15] randomized 80 patients at the time of diagnosis by cholangiography to either laparoscopic exploration or delayed postoperative EST. Patients were excluded if they had preoperative EST, cholangitis, or acute pancreatitis. The laparoscopic approach entailed transcystic exploration (n = 28) of the duct followed, if necessary, by laparoscopic choledochotomy (n = 12) in those patients with CBD exceeding 6 mm in diameter. This study showed that both techniques were associated with a 75 % successful bile duct clearance rate at the time of first intervention. Final duct clearance was not significantly different, although there was a trend towards better clearance with the laparoscopic approach. The length of hospital stay was significantly shorter with the singlestage approach (1 day, 3.5 day; p < 0.001). There was no significant difference in morbidity (18 %, 15 %; p = NS) or mortality (0 %, 0 %). However, the authors concluded that the transcystic approach was preferred.

These patients are best managed by endoscopic clearance, which is considered as the least morbid procedure. Failure rates of upto 10 % have been reported [18]. In these situations the treatment options are either laparoscopic or open exploration depending on the surgical expertise and resources at disposal.

Review of Literature

For patients who are fit for surgery, the choice is between single stage operative exploration of CBD or a sequential approach i.e. preoperative or postoperative ERCP with EST along with laparoscopic cholecystectomy. ERCP has a morbidity rate of 5 to 9.8 % and a mortality rate of 0.3 to 2.3 % [19, 20], mostly due to postoperative acute pancreatitis, duodenal perforation and bleeding. Moreover it causes injury to the sphincter of Oddi which should be avoided in patients younger than 60 years [21, 22]. Recent studies indicate that one-stage management of CBD stones with LCBDE has less morbidity and mortality and is cost-effective with a short hospital stay [23]. It treats both gallstones and CBD stones in single stage compared with sequential procedures, and is performed as a daycare procedure [24]. LCBDE also preserves the function of sphincter of Oddi and hence prevents reflux-related complications, such as cholangitis and recurrent stones associated with sphincter damage [21]. Performing ERCP contextually to LC implies organizational problems concerning the availability of an endoscopist in the operating theater whenever needed. Finally, performing ERCP after surgery would raise the dilemma of managing CBD stones whenever ERCP fails to retrieve them because a third procedure would then be needed.

A Cochrane systematic review by Martin et al. [3] concluded that a single-stage treatment of bile duct stones via the cystic duct approach was recommended for intraoperatively discovered CBD stones. In patients where it is not possible to clear the duct by this approach, a delayed postoperative ES should be the preferred option in most centers. However, it was also noted that the reported experience is limited, and larger randomized trials are warranted to compare these therapeutic options.