BILE-DUCT STONES IN THE LAPAROSCOPIC ERA - IS PREOPERATIVE SPHINCTEROTOMY NECESSARY

Objective: To evaluate treatments for common bile duct stones (CBDS). Design: Retrospective review of authors' case series. Setting: Large p rivate metropolitan teaching hospital. Patients: All patients with CBD S (N=145) from a series of 1231 patients who underwent laparoscopic ch olecystectomy, 99% with intraoperative fluorocholangiography. Interven tions: Treatments for CBDS included one or more of the following: lapa roscopic transcystic duct exploration (n=123), laparoscopic choledocho tomy (n=10), open choledochotomy (n=7), preoperative endoscopic sphinc terotomy (ES) (n=9), intraoperative ES (n=2), postoperative ES (n=11), or observation (n=10). Main Outcome Measures: Success of various inte rventions for CBDS, morbidity and mortality, frequency of retained sto nes, operative time, and length of postoperative hospitalization. Resu lts: Laparoscopic transcystic duct exploration was successful in 91% o f attempts and resulted in the shortest postoperative stay (3.4 days), least morbidity (5%), and fewest retained stones (5%). Endoscopic sph incterotomy was successful in 56% of preoperative attempts, 50% of int raoperative attempts, and 91% of postoperative attempts. There were no reoperations and one death. Conclusions: For patients requiring chole cystectomy, laparoscopic transcystic duct exploration is safe and effe ctive, treats CBDS in one session, and if unsuccessful still allows fo r open choledochotomy or postoperative ES. Preoperative endoscopic ret rograde cholangiography and ES should be reserved for patients with se rious illness or possible malignant disease.