Management of unsuspected common bile duct stones found during laparoscopic cholecystectomy by means of transcystic catheter placement and papillary dilation

Background: The optimal treatment strategy for treatment of bile duct stone s first diagnosed during laparoscopic cholecystectomy has not been establis hed. We prospectively treated unsuspected bile duct stones by means of intr aoperative placement of a transcystic catheter followed by postoperative ph armacologic papillary dilation or endoscopic papillary balloon dilation. Methods: In 17 patients with bile duct stones first found at laparoscopic c holecystectomy, a catheter was introduced via the cystic duct into the bile duct. If postoperative cholangiography via a transcystic catheter showed s tones 5 mm or less in diameter, glyceryl trinitrate was infused via the cat heter into the bile duct. Patients in whom medical dilation was unsuccessfu l or who had larger stones underwent endoscopic papillary balloon dilation. Results: Stone diameter measured 3 to 11 mm (mean 6.4 mm). Postoperative ch olangiography revealed spontaneous passage in four patients. After pharmaco logic papillary dilation, two of five patients with stones 5 mm or less in diameter had stone clearance. The remaining 11 patients underwent successfu l endoscopic papillary balloon dilation with stone clearance. In two patien ts, a guidewire introduced via a transcystic catheter through the papilla f acilitated selective biliary cannulation. One early minor complication occu rred. All patients remained without symptoms for a mean followup of 13 mont hs. Conclusion: For unsuspected bile duct stones (usually small ones), this str ategy is a simple and effective alternative to laparoscopic bile duct explo ration and postoperative sphincterotomy and may minimize early and late com plications. Transcystic catheterization ensures access to the bile duct, th ereby avoiding endoscopic treatment failures.