Actual management of common bile duct stones: a continuous evolving approach

The management of common bile duct stones (CBDS) has recently changed regarding either a more precise diagnosis of patients at high-risk to harbor CBDS and either the development of new therapeutic modalities. In patients with preoperative predictive suspicion of CBDS, new non-invasive radiologic and endoscopic investigations are now available, namely 3-D spiral CT-cholangiography and magnetic resonance cholangio-pancreatography on one hand, and endoscopic ultrasonography on the other hand. With the development of laparoscopic surgery, two strategies have emerged in order to maintain the minimally invasive nature of the procedure: perioperative endoscopic sphincterotomy or laparoscopic common bile duct exploration. However, considerable laparoscopic expertise, advanced and expansive technologies are required to achieve successful laparoscopic treatment of CBDS. An appropriate intraoperative strategy is mandatory during laparoscopic common bile duct exploration, with specific indications for the transcystic route and for laparoscopic choledochotomy, according to patient's biliary anatomy and stone's characteristics. A preliminary controlled trial has proved the safety, efficacy and excellent postoperative results of such approach. However, the best option of management for patients with CBDS remains open to discussion and the therapeutic choice should depend on the local hospital availability of technical expertise.