Management of preoperatively suspected choledocholithiasis: a decision analysis

Area of Science:

• Gastroenterology
• Surgical Innovation
• Biliary Tract Disease Management

Background:

• Management of common bile duct (CBD) stones remains controversial, affecting 5-15% of patients undergoing cholecystectomy.
• Patients with symptomatic choledocholithiasis have a higher incidence of CBD stones.
• Current treatment options include preoperative ERCP/ES, LC/IOC with LCBDE, or double-lumen catheter placement.

Purpose of the Study:

• To determine the optimal management strategy for patients with suspected common bile duct stones.
• To compare the efficacy and safety of different treatment modalities.
• To analyze decision-making based on morbidity and mortality rates.

Main Methods:

• Decision analysis model to evaluate management options for suspected CBD stones.
• Comparison of preoperative ERCP/ES followed by LC, LC/IOC followed by LCBDE, and double-lumen catheter placement.
• Literature-based data on morbidity and mortality, with sensitivity analysis on positive IOC incidence.

Main Results:

• One-stage LC/LCBDE demonstrated significantly lower morbidity (7%) and mortality (0.19%) than two-stage preoperative ERCP/ES (13.5% and 0.5%).
• Even with 100% positive IOC, LC/LCBDE morbidity (9.4%) remained lower than two-stage management.
• Double-lumen catheter use increased morbidity above two-stage management only if positive IOC incidence exceeded 65%.

Conclusions:

• LCBDE is associated with superior outcomes (lower morbidity and mortality) compared to preoperative ERCP/ES for suspected CBD stones.
• LCBDE is recommended even when the likelihood of CBD stones is high.
• A double-lumen catheter is a viable alternative if LCBDE is not feasible and stone incidence is below 65%.