THE EVALUATION AND MANAGEMENT OF KNOWN OR SUSPECTED STONES OF THE COMMON BILE-DUCT IN THE ERA OF MINIMAL ACCESS SURGERY

Laparoscopic cholecystectomy (LC) has rapidly become the procedure of choice for symptomatic cholelithiasis. The perioperative diagnosis and modern treatment of suspected stones of the common bile duct (CBD) re mains controversial. A database of 573 patients undergoing LC was comp iled during an 11 month period. Sixty-seven patients (47 females, 20 m ales) (13 percent) were suspected of having CBD stones based upon clin ical, laboratory and roentgenographic evidence. Fifty-two patients und erwent endoscopic retrograde cholangiopancreatography (ERCP) (45 preop erative and seven postoperative). Seventeen patients were studied with intraoperative cholangiogram (IOC). The indications for cholangiograp hy (either ERCP or IOC) included pancreatitis (group 1), clinical hist ory suggestive of CBD stones, but normal preoperative liver function t ests (LFT) (group 2), cholangitis (group 3), grossly abnormal LFT (gro up 4) and dilated CBD (greater than 7 millimeters on sonogram) (group 5). The incidence of CBD stones was three of 14 (21 percent) in group 1, six of 20 (30 percent) in group 2, two of three (67 percent) in gro up 3, 16 of 26 (62 percent) in group 4 and two of four (50 percent) in group 5. Overall, 29 patients (23 females and six males) had stones r etrieved from the CBD. Of the 52 ERCP, 20 endoscopic sphincterotomies were performed for documented CBD stones. Of the group that had pre-LC ERCP, three (6 percent) ultimately required an open procedure. There were three instances of post-ERCP pancreatitis (6 percent) and ERCP wa s not able to opacify or clear the CBD in four instances. Seven patien ts had postoperative ERCP with successful retrieval of retained CBD st ones (100 percent). Of the 17 IOC, eight were positive-two patients un derwent laparoscopic clearance of the CBD and six required conversion to an open procedure. There were no deaths or extensive complications. Total and direct bilirubin, alkaline phosphatase and serum glutamic p yruvic transaminase were independently related to the presence of a CB D stone, while demographic data, past medical history, preoperative sy mptoms, leukocyte count, vital signs, amylase, serum glutamic-oxalacet ic transaminase nuclear scintigraphic visualization of the duodenum or size of CBD on sonography, were not. No patient with biliary pancreat itis had CBD stones without abnormalities in the LFT or the preoperati ve sonogram. ERCP is a useful technique to clear the CBD pre-LC. Howev er, ERCP in patients with biliary pancreatitis, but otherwise normal p reoperative tests, has a low yield. In this group of patients, IOC is an appropriate alternative to pre-LC ERCP.