The current management of common bile duct stones

Choledocholithiasis is usually proven by cholangiogram during cholecystectomy, and today nearly all cholecystectomies are performed laparoscopically. Patients expect to be discharged from the hospital within 24 hours after laparoscopic surgery and return to work in 1 week. Surgeons must develop advanced laparoscopic skills to allow choledocholithiasis to be managed laparoscopically with one procedure and one anesthetic. Interventional radiologists and gastroenterologists can frequently detect and manage common duct stones that cause severe cholangitis and pancreatitis and that occur in patients too debilitated for general anesthesia. In the majority of patients, common duct stones demonstrated at laparoscopic cholecystectomy may be removed using laparoscopic transcystic techniques. Whether complicated CBD stones are optimally managed by laparoscopic choledochotomy, conversion to open common duct exploration, or left for postoperative ERC/ES is controversial and depends on the expertise of the surgeon, gastroenterologist, and wishes of the patient. Although the authors propose one algorithm for the current management of CBD stones, the superiority of the laparoscopic treatment for CBD stones is not yet proven. Multi-institutional, randomized trials comparing laparoscopic, endoscopic, and combined techniques for ductal clearance will be necessary to establish the optimal therapy of choledocholithiasis in the 1990s.