Management of common bile duct stones in a single operation combining laparoscopic cholecystectomy and perioperative endoscopic sphincterotomy

Background: Laparoscopic cholecystectomy (LC) has become the reference trea tment for biliary lithiasis, but the management strategy for common bile du ct stones (CBDS) remains a subject of controversy in the absence of an esta blished consensus. While conventional surgery remains the reference treatme nt for CBDS, minimally invasive techniques are becoming more and more popul ar. These methods consist of the extraction of the common bile duct stones either exclusively by laparoscopy or by sequential treatment with endoscopi c sphincterotomy (ES) followed by LC. The aim of this study was to evaluate the treatment of CBDS in a one-stage operation by laparoscopic cholecystec tomy (LC) and perioperative endoscopic sphincterotomy. Patients and methods : Between January 1994 and March 1998, 44 patients, 20 male and 24 female, (sex ratio 1.2) with a median age of 57 years (range 28-84 years) were trea ted for suspected or confirmed CBDS. The CBDS were uncomplicated in 39 case s (88%) and associated with a complication in 5 cases (12%), namely, cholan gitis (2 cases) or acute pancreatitis (3 cases). The perioperative ES was performed immediately after the LC during the same operative time, with perioperative cholangiography being systematically pe rformed (1 failure). In 6 cases, a transcystic drain was left in place (to ensure complete evacuation of the CBDS postoperatively) when there were mor e than three stones and/or when they were larger than 6 mm. The patient was positioned in the left lateral position in order to perform the ES. Result s: Mean operative time for LC was 60 min, range 40-90 min. The general anes thesia was prolonged by 40 min in order to perform an ES (range 30-60 min). The perioperative ES was unsuccessful in one case (2%), due to the impossib ility of catheterizing the papilla, the preoperative MR cholangiogram being normal. Immediate clearance of the CBD was achieved in 95% of the cases (4 2 p). In 2 cases, residual stone was found in the sixth day after cholangio graphy and was spontaneously evacuated as shown by 21st-day control. There was no mortality or postoperative complications. The duration of the postop erative hospitalization was 4.6 days (range 3-6). Conclusions: We believe that LC combined with perioperative ES is a quick, reliable, and safe technique for the treatment of CBDS during a single oper ative procedure, although this approach is limited by the proximity and ava ilability of an endoscopic team.