Common bile duct stone characteristics: Correlation with treatment choice during laparoscopic cholecystectomy

Determining the most appropriate management approach for patients with unsu spected choledocholithiasis may be difficult because of the subjective natu re of this decision in the absence of clinical data. Treatment of incidenta l choledocholithiasis during laparoscopic cholecystectomy was relieved duri ng a 25-month period. Operative cholangiographs were analyzed retrospective ly to determine if associations exist between common bile duct stone charac teristics and the intraoperative treatment selected by the operating surgeo n. Cholangiographic data included quantification of common bile duct stunts , stone dimension, position, and presence of radiopaque contrast: flow into the duodenum. Two hundred thirty-six laparoscopic cholecystectomy patients underwent operative cholangiography; 25 (11%) demonstrated choledocholithi asis. Seven patients were converted to open common bile duct exploration (g roup I), 16 patients were referred for postoperative endoscopic retrograde cholangiopancreatography (group II), and two patients were observed (group III). Evaluation of the operative cholangiograms revealed multiple common b ile duct stones (>1) in 86% (6 of 7) in group I, 25% (4 of 16) in group II, and none in group III. All patients in group I had at least one stone larg er than 5 ml in greatest diameter, whereas only 33% (6 of 18)in groups TT a nd III combined had stones larger than 5 mi. Group I hall significantly (P = 0.027) more representation of delayed or no contrast flow during operativ e cholangiography compared to groups II and III. The intraoperative decisio n to proceed with laparoscopic cholecystectomy and rely on post operative e ndoscopic retrograde cholangiopancreatography for stone retrieval rather th an open common bile duct exploration was associated with (1) a single commo n bile duct stone, less than or equal to 5 mi in size on operative cholangi ogram and (2) normal contrast flow into the duodenum. Open common bile duct exploration was more frequently associated with the demonstration of multi ple or large (>5 ml) stones. A periampullary stone did not discriminate amo ng treatment choices.