THE MANAGEMENT OF COMMON BILE-DUCT STONES IN PATIENTS UNDERGOING LAPROSCOPIC CHOLECYSTECTOMY

The management of suspected and/or unsuspected common bile duct (CBD) stones in patients undergoing laparoscopic cholecystectomy (LC) is con troversial. Decisions on whether to perform an open CBD exploration ve rsus employing therapeutic options such as pre-operative/post-operativ e endoscopic retrograde cholangiography (ERCP) or endoscopic duct expl oration are polemic. To determine indications, timing, benefits, and p otential morbidity of these approaches, we gathered data on 401 patien ts undergoing LC within the last 18 months. Indications for preoperati ve ERCP included jaundice (40%), dilated ducts (28%), elevated amylase (19%) or alkaline phosphatase (21%), suspicion of CBD stones by ultra sound (17%) and ''other'' (17%). Indications for postoperative ERCP we re retained stones (33%) and CBD evaluation (67%). Indications for CBD exploration included abnormal cholangiogram (64%), palpable stones (1 8%), and other (18%). A significant correlation was observed between s uspected stones by ultrasound and stones found by ERCP (P < 0.01). For patients in the ''other'' category, preoperative ERCP was universally negative (P = 0.04). Overall ERCP morbidity was 4/59 (6.8%), and the overall failure rate for clearing CBD stones was 2/28 (7.1%). The timi ng of the ERCP did not affect morbidity/mortality. Multivariate analys is revealed that age (P << 0.001), the presence of pre-existing medica l risk factors (P << 0.001), and duration of LC (P = 0.0034), but not ERCP (P = 0.08), were the important factors determining LC morbidity. In summary, common bile duct stones can be successfully cleared endosc opically in the majority of patients undergoing LC. Patients with susp ected CBD stones should undergo preoperative ERCP, and strict criteria should be applied in the selection of these patients. Patients with s ilent stones discovered during LC should be considered for postoperati ve ERCP. Pre-/post- ERCP are safe therapeutic options in patients with suspected/corroborated CBD stones who are undergoing LC. In patients who are converted to an open procedure, CBD exploration remains the go ld standard.