[Sequential treatment of lithiasis of the common bile duct]

The purpose of this study is to evaluate the sequential endoscopic-laparoscopic approach for clearance of common bile duct (CBD) and removal of gallbladder in patients with simultaneous cholecystolithiasis and choledocholithiasis. A data base of 990 patients undergoing Laparoscopic Cholecystectomy (LC) was compiled during an 5 years period. 88 patients were suspected of having CBD stones based upon clinical, biological and ultrasound evidence. The CBD cannulation rate was 93% (82/88). CBD stones were found in 43 patients (49%). The stones were removed preoperatively by Endoscopic Sphincterotomy (ES) in 37 patients of these 43 cases (86%). LC was performed in all patients after endoscopic retrograde cholangiopancreatography (ERCP). This treatment had showed no mortality and a morbidity of 14%. Efficacy of this sequential method of treatment of LVBP was 86%. With inclusion of laparoscopic extractions, the efficacy rate was 91%. The rate of residual stones was 1% (1/88). Experience with ERCP and ES before LC has been growing. ERCP-SE in the treatment of choice to clear the CBD before LC in high risk elderly patients (26) as well as in complicated stones. However, in this era of laparoscopic surgery, CBD stone can be removed laparoscopically in specialized centres with the advantage of a non-invasive single procedure for the patient. Laparoscopic CBD desobstruction and ES are not opposite but complementary. Preoperative ERCP and ES should be reserved for patients with serious illness. All other patients should be managed laparoscopically; in this case the future of sequential treatment resides in a one step-approach: preoperative ERCP if cholangiography is positive.