LAPAROSCOPIC CHOLECYSTECTOMY AND COMMON BILE-DUCT STONES - VALUE OF PREOPERATIVE ENDOSCOPIC ULTRASONOGRAPHY AND ENDOSCOPIC RETROGRADE CHOLANGIOGRAPHY

Objectives. - Laparoscopic cholecystectomy is the standard treatment o f symptomatic gallstones. At present, no consensus has been reacted on the diagnostic and therapeutic Methods of concomitant common bile duc t stones. Systematic preoperative endoscopic ultrasonography followed, if necessary, by endoscopic retrograde cholangiography and sphinctero tomy during the same anesthetic procedure could be a diagnostic and th erapeutic alternative for common bile duct stones making possible a la proscopic cholecystectomy without intraoperative investigation of the common bile duct. Methods. - One hundred and twenty-five patients unde rwent a prospective endoscopic ultrasonographic evaluation prior to la paroscopic cholecystectomy for symptomatic gallstones. Fourty-four pat ients (35 %) had at least one predictive factor for common bile duct s tones. Endoscopic ultrasonography and cholecystectomy were performed o n the same day. Endoscopic ultrasonographic was followed by endoscopic retrograde cholangiography and sphincterotomy by the same endoscopist in case of common bile duct stones on endoscopic ultrasonography. Pat ients were routinely followed up between 3 and 6 months and one year a fter cholecystectomy Results. - Endoscopic ultrasonography suggested c ommon bile duct stones in 21 patients (17%). Endoscopic ultrasonograph y identified a stone in 17 of 44 patients (38,6 %) with predictor of c ommon bile duct stones and only in 4 of 81 patients (4,9 %) without pr edictor of common bile duct stone. Among these 21 patients, one patien t was not investigated with endoscopic retrograde cholangiography beca use of the high risk of sphincterotomy, 19 patients had a stone remove d after sphincterotomy, one patient had no visible stone neither on en doscopic retrograde cholangiography, nor on exploration of the common bile duct after sphincterotomy. Endoscopic ultrasonography was normal in 104 patients (83 %). However two patients in this group in were inv estigated with endoscopic retrograde cholangiography because endoscopi c ultrasonography was incomplete in one case and because endoscopic ul trasonography? was normal in the second case but a stone in the left h epatic duct was detected by ultrasonography. A stone was removed after endoscopic sphincterotomy in these two patients. In the group of 102 patients without stone, 91 out of 92, continued to be asymptomatic dur ing a median follow-up of 8.5 months. One patient with symptoms one mo nth after cholecystectomy underwent endoscopic sphincterotomy but no s tone was found. Conclusion. - Systematic preoperative endoscopic ultra sonographic followed, if necessary with endoscopic retrograde cholangi ography and sphincterotomy is a diagnostic and therapeutic alternative for common bile duct stones making possible a laparoscopic cholecyste ctomy without intraoperative investigation of the common bile duct for all patients. This alternative is only justifiable in patients with p redictor of common bile duct stones.