Controversies in the management of common duct calculi

Patients less than 65 years of age who have symptomatic cholelithiasis should undergo laparoscopic cholecystectomy with interoperative cholangiography. When calculi are encountered, the transcystic duct technique of bile duct exploration is applicable in 80% to 90% of patients. When the common bile duct calculus is larger than 1 cm, the patient is a candidate for laparoscopic choledochotomy. Based on present data, when the patient is less than 65 years of age, open common bile duct exploration is safer than endoscopic sphincterotomy, although in the future we may have long-term follow-up studies on endoscopic sphincterotomy in this younger age group. Patients more than 65 years of age undergoing elective laparoscopic cholecystectomy are candidates for preoperative endoscopic sphincterotomy if they have an ultrasound diagnosis of choledocholithiasis or a high likelihood of harboring common bile duct calculi. They are also candidates for laparoscopic techniques of common bile duct exploration and intraoperative or postoperative endoscopic sphincterotomy. Open surgery and biliary bypass should be considered in complex situations that are not suitable for endoscopic sphincterotomy. Finally, local expertise and the complexity of the individual case influence the treatment of patients with choledocholithiasis.