Management of calculi in the common duct

Management of choledocholithiasis requires several strategies to solve the various clinical problems encountered. A maximal effort during cholecystectomy at discovery of the duct stones in almost one of every six patients should, of course, be continued. Cystic duct cholangiography should routinely be used in deciding whether to explore the common duct. Postexploratory choledochoscopy has demonstrated discovery value and will hopefully be increasingly used. More training and sharing of technical details is indicated. When a retained stone is discovered on T tube cholangiogram, several options are available with no one clearly superior. Waiting for the T tube tract to mature and attempting extraction via flexible endoscopes or Burhenne technique is probably most cost effective if appropriate skills are available, especially for small calculi. Calculi greater than 8 mm in diameter with some probability of having high cholesterol content may be best managed with monooctanoin infusion. Parenthetically, monooctanoin dissolution may reduce morbidity of ERS, since large stones that would require large, more risky sphincterotomies can in some instances be reduced to passable size by monooctanoin infusion via an endoscopically placed nasobiliary tube. Endoscopic sphincterotomy for retained stones is ordinarily reserved for patients in whom nonoperative retrieval has failed or the T tube has fallen out. When common duct obstruction due to stones occurs prior to or remote from cholecystectomy, ERS is the preferred method of management when available, under conditions previously noted. With improved discovery methods and less morbid therapeutic options, consequences of choledocholithiasis will be less formidable.