MANAGEMENT OF BILE-DUCT STONES IN THE ERA OF LAPAROSCOPIC CHOLECYSTECTOMY - APPRAISAL OF ROUTINE OPERATIVE CHOLANGIOGRAPHY AND ENDOSCOPIC TREATMENT

Objective: To assess the value of preoperative or postoperative endosc opic treatment of bile duct stones and routine use of operative cholan giography (OC) for detection of unsuspected common bile duct (CBD) sto nes in conjunction with laparoscopic cholecystectomy. Design: Prospect ive study. Setting: University hospital, Sweden. Main outcome measures : Diagnostic and therapeutic yield of stones at endoscopic retrograde cholangiography (ERC) before or after laparoscopic cholecystectomy and routine operative cholangiography. Results: Of 630 patients who under went laparoscopic cholecystectomy, 84 had preoperative ERC. Of these 8 4, 47 (56%) had bile duct stones. Endoscopic sphincterotomy was done f or all 47, of whom 3 (6%) had retained stones at OC. OC was done for 5 90 (94%) of the 630 patients, and 45 (7.6%) were found to have choledo cholithiasis. At postoperative ERC, however, 10 of these patients were free of stones and there were two cases of false negative OC, which r esulted in sensitivity and specificity of OC of 95% and 98%, respectiv ely. Thus, 35 patients (6%) had bile duct stones discovered at OC, of whom 33 had ''unsuspected'' stones. Of these 35 patients, 29 were clea red endoscopically after cholecystectomy. The remaining 6 patients wer e cleared of stones either by open choledocholithotomy (n = 2) or by l aparoscopic transcystic manipulation (n = 4). There was no mortality a fter diagnostic or therapeutic ERC:, and morbidity was confined to two cases each of pancreatitis and cholangitis, which resulted in a compl ication rate of 3% (4/118). No complications resulted from IOC. Conclu sions: Preoperative ERC should be done for patients with symptoms or f indings indicating ductal calculi. In most patients undergoing laparos copic cholecystectomy, OC is feasible and its routine use is strongly advocated. Bile duct stones diagnosed at OC can safely and successfull y be treated endoscopically after laparoscopic cholecystectomy. Until laparoscopic bile duct exploration becomes routine and generally appli cable, endoscopic management of bile duct stones both before and after cholecystectomy will be an important therapeutic option.