Management of choledocholithiasis in the era of laparoscopic surgery

Laparoscopic biliary surgery is changing the management of choledocholithia sis. Between November 1989 and December 1998, 2834 cholecystectomies were p erformed at two institutions. Choledocholithiasis was suspected in 420 pati ents on the basis of elevated preoperative laboratory and ultrasound criter ia [bilirubin, alkaline phosphatase, serum glutamic-oxaloacetic transaminas e, serum glutamate pyruvate transaminase, and common bile duct (CBD) size]. One hundred seventeen patients had preoperative endoscopic retrograde chol angiopancreatography (ERCP) because of persistent elevation in their enzyme s beyond 24 to 48 hours or as an emergency. Laparoscopic intraoperative cho langiogram was attempted in 329 patients whose enzymes fell rapidly within the first 24 to 48 hours or had a failed ERCP. Eighty-one of the 329 were f ound to have stones. Seventy-three had laparoscopic attempt to clear the CB D, with success in 62 patients (85%). This included 41 transcystic duct and 21 direct CBD exploration. Eight patients had postoperative ERCP for retai ned stones. Six (0.25%) were in patients with normal preoperative enzymes. We conclude that choledocholithiasis can be suspected with preoperative lab oratory and ultrasound criteria. By waiting 24 to 48 hours (except in an em ergency), a good number of CBD stones will pass. With increases in laparosc opic experience, laparoscopic removal of CBD stones may replace preoperativ e ERCP. The small number of cases of retained or missed stones that occur w ith the use of selective cholangiography can be easily handled with postope rative ERCP.