Incidental Intraoperatively Detected Choledocholithiasis: A General Surgeon's Approach to Management

Area of Science:

• Gastroenterology
• Hepatobiliary Surgery
• Diagnostic Imaging

Background:

• Choledocholithiasis complicates up to 15% of cholelithiasis cases, with nearly 10% missed pre-operatively.
• Incidental diagnosis during routine intra-operative cholangiogram (IOC) is common.

Purpose of the Study:

• To quantify incidental choledocholithiasis during IOC.
• To identify optimal management strategies.
• To determine reliable pre-operative predictors.

Main Methods:

• Retrospective cohort study of 880 patients undergoing cholecystectomy.
• Analysis of intra-operative cholangiogram findings and pre-operative predictors.
• Review of management pathways including hyoscine butylbromide, octreotide, trans-cystic bile duct exploration (TCBE), and postoperative endoscopic retrograde cholangiopancreatography (ERCP).

Main Results:

• Overall choledocholithiasis rate was 10.6%, with 6.6% diagnosed incidentally during IOC.
• Hyoscine butylbromide (50% of cases) had a 55.2% success rate; octreotide (22.4%) had a 61.5% success rate.
• TCBE and postoperative ERCP achieved 100% success rates.
• Gallstone pancreatitis, elevated AST/ALT levels, and common bile duct (CBD) diameter ≥8 mm on imaging were associated with choledocholithiasis.

Conclusions:

• One in ten cholecystectomies are complicated by choledocholithiasis, with over half incidentally found during IOC.
• Proposed first-line treatment includes IOC with hyoscine butylbromide, octreotide, and saline flushes, followed by TCBE if unsuccessful.
• Gallstone pancreatitis, significantly elevated liver enzymes, and a dilated CBD (≥8 mm) on imaging are key predictors.