Role of open choledochotomy in the treatment of choledocholithiasis

In recent years, several less invasive procedures have challenged the preeminence of open choledochotomy in the management of patients with choledocholithiasis. Alternatives now include endoscopic sphincterotomy, extracorporeal shock-wave lithotripsy, percutaneous transhepatic stone extraction, and laparoscopic common duct exploration. In deciding whether an alternative is appropriate for an individual patient, factors to consider include the following: (1) the presence or absence of the gallbladder; (2) the severity of the presenting symptoms; (3) the results of open choledochotomy; and (4) local endoscopic, radiologic, and laparoscopic expertise. Review of available data suggests that endoscopic sphincteroplasty is appropriate for older patients without a gallbladder and for those with severe toxic cholangitis. However, endoscopic sphincterotomy has not been proven to be worthwhile before open surgery. Open choledochotomy has been reported to have a mortality rate of less than 2%, leaving fewer than 5% of patients with retained stones. Since the introduction of laparoscopic cholecystectomy, treatment algorithms for patients with common duct stones have seldom included open choledochotomy. However, future prospective, randomized trials of the management of patients with choledocholithiasis should include open choledochotomy as the gold standard.